Attempt to Assure Quality of Care Management Practice by a Municipal GovernmentRie yamanoi 　 　 QZD11275@nifty.ne.jp Meisei University, Department of Sociology and Human Welfare

AbstractThis study examines the functions of a care management training

program using a case study of a municipal government’s attempt to evaluate and improve care management practice.

Since the enactment of the Long-term Care Insurance (LTCI) system in Japan, care management has expanded in the social care area for the disabled elderly. However, the quality of the care management process is not always adequate. Recently, various organizations have launched efforts to improve the quality of care management. In 2003, Musashino City, a suburb of Tokyo, initiated a training program for care management.

Committee members in this program evaluate the care management process based on care plans and records as well as the user’s evaluation and their own self evaluation of the care management process from eight perspectives: 1) assessment; 2) confirmation of user’s intention; 3) definition of user’s needs; purpose of care, and resources to meet user’s needs; 4) weekly care plan; 5) care conference,6) care management process; 7) monitoring, and ８ ) overall evaluation. After the committee meeting, the care management leaders visit care managers in the field in order to explain their evaluation, provide training lectures about care management and listen to care managers’ work issues. Further, care management leaders inform the committee as to the reaction of care managers after these visits. This training program can be examined in terms of three supervisory functions (Kadushin and Harkness 2002).First, there is the administrative function by which the local government as an insurer confirms the quality of care management practice for the insured person. Second, there is the educational function for care managers to acquire necessary skills. Third is the supportive function by which the care management leaders provide support to care managers with anxiety problems caused by a lack of supervisors and colleagues in their workplaces.

1. Long-Term Care Insurance and Care ManagementCare Management in Long-Term Care Insurance.　 In Japan, researchers have introduced the concept of care management since the 1980s using English and American studies of care management such as the Kent Project (Challis and Davis 1986). In the community care support center established in 1990, social workers have adopted care management as a method to intervene with users (Soeda 1997; Soeda

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2004). However, care management has become better known since the enactment of the Long-Term Care Insurance (LTCI) Act in 2000. When individuals wish to use care services covered by LTCI, they may apply directly to municipal government or ask someone in a care management agency to apply on their behalf. Next, an examiner visits their at home to check on their condition. Then, based on the information gathered by the examiner’s interview and observations, a primary decision is made using a computerized process. Finally, referring to the Statement of Doctor’s Opinion provided by their family doctor, the Care Authorization Board, made up of specialists in the health, medical and welfare fields, examines the validity of the initial decision and makes a final decision (Required Care Authorization). The upper limit of available services a user can receive from the insurance depends on the level of care authorized. Then, users requested a care manager to design a care plan consisting of care services based on their needs. Although users can design their own plan without involving a care manager, most users ask to a care manager because this service is free for users and families.

Care management and problemsWhen LTCI was enacted, a new category of ‘care managers’, requiring licensing and over five years of experience in health and welfare fields, was created in order to support LTCI users in selecting care services. Since the enactment of LTCI, the number of people who are licensed ‘care managers’ has been increasing. As this growth occurred, some problems concerning care managers have appeared.

First, it is difficult for care managers to maintain neutrality. In Japan, many of them are employed with for-profit social care service providers. Additionally, the central government often decides on care management reward so low that it does not fully pay for all care management services. Therefore, care managers are often forced to not use other providers’ services based on users’ actual needs but to select services offered by their own agencies, even though care managers argue that the other providers’ services would be better to meet their users’ needs.

Second, the care managers’ workload becomes too heavy because their employers order their care managers to take on far to many users in order to pay for their care management. In general, an adequate caseload for one care manager is approximately 50 individuals, but many care managers have well over 50, sometimes even more than 100 individuals. Furthermore, the government mandates that care managers are under an obligation to monitor their users regularly, without considering the degree of need for care managers’ support based on their users’ actual conditions and problems.

Third, not all care managers are experienced or trained well enough to take part competently in community care. In order to acquire a care manager license an applicant who has any license and experience in health

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and welfare fields is required only to pass a simple written examination and attend short-term seminars. This process is simply not adequate to train someone in this new specialty. In most cases, care managers work with users and families not as care managers but rather as their basic occupations: nurses, social workers, care workers and other professionals. Therefore, it is necessary to clarify further the care managers’ specialty and to standardize their work based on the full definition of 　 this new specialty.

Attempts to assure proper care managementRecently, some local governments’ have attempted to standardize the

quality of care management through enhancing care managers’ competency in light of these under such unstable conditions in Japan. Toyama City started a training program to correct the individual care plans that care managers were submitting (Kunimitsu, T., and Toyama City 2004), and Fuchu City developed a program in which committees directly supervise how to design plans for individual care managers (Department of Welfare, Tokyo Metropolitan, Conference of Support 　 for Care Managers in Tokyo　 2004 ； Kamata 2005; Someya 2005).

In this presentation, I would like to examine a pioneering care management training program, with which I have been concerned as a vice chairperson, implemented by a municipal government in Japan.

2. MethodsSubject of case studyThe subject of this study is the evaluation and supervision program of care mananagement that Musashino City, a suburb of Tokyo, started in 2003. the Musashino City commissioned the Musashino Welfare Public Company in November 2002 to manage the care manager training institute in order to assure the quality of care management. Their main program contains the following; 1) a training course for beginners, advanced care managers, and special subjects; 2) an evaluation and supervision program of care management; and 3) consultation and advice for care management.

Study methodsThis study’s main aim is to examine the functions and benefits of the evaluation and supervision program of care management, analyzing procedures and processes in the program from the view point supervision of Kadusin and Harkness (2002): 1) administrative supervision,2) educational supervision, and 3) supportive supervision.

Administrative supervisionAdministrative supervision means primarily managerial functions. Supervisors manage staff members to ensure their accountability as performing members of their service agency. Facilities and agencies

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providing social care services are responsible to users and the community to deliver adequate services by managing each professional’s work. Supervisors have to work with their staff members to outline their work as a member of that agency, and thus supervisors must explain policies of agency and job responsibilities to staff members, assign jobs in consideration of a staff member’s ability, and confirm whether staff members achieve their assigned roles adequately. These explanations, assignments, and performance evaluations enable supervisors to effectively manage staff members’ services to users and their community.

Educational supervisionEducational supervision means encouraging staff members’ abilities, which consist of knowledge, skills and values, to further the objectives of the agency in meeting users’ and the community’s needs. 　 In order to deliver adequate services, professionals must to use their required knowledge and skills effectively in their work process as just well as acquiring more knowledge and skills. Additionally, staff members must acquire professional values and ethics.

Many professionals try to gain practical knowledge and skills from only lectures in schools and training, and textbooks. Yet, they often merely understand the apparent concepts from words. They need to study in more depth by linking academic concepts with actual practice, looking back on their interventions from an actual helping process and discuss

improving intervention skills, so that they can fully activate those concepts into day-to-day practices.

Additionally it is indispensable for staff members to learn values and ethics as care management professionals. For example, supervision helps staff members understand values and ethics, such as how to support users’ decisions, in a closer relationship actual user, and consequently staff members deepen their understanding of quality care management.

Supportive supervisionSupportive supervision means alleviating staff members’ occupational stress and empowering their competencies as professionals.

Helping professionals are always exposed to so much stress that they often encounter human anger and unhappiness. Many of us have the ability to cope with a certain amount of stress by our nature. However, heavy and long-term stress deadens our sensitivity to reactto users’ conditions and may cause apathy. If helping professions suffer from such a ‘burn-out syndrome’, it is difficult for them to be able to achieve their roles.

Table 1 　　　Care Manager’s Self－evaluation Sheet

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1. Are you concerned about not causing discomfort to the user and his/her family? 2. Do you provide an easy to understand overall explanation of the Long-term Care Insurance system? 3. Did you also explain available services available other than those of the Long-term Care Insurance system? 4. Do you explain sufficiently methods to use the services?5. Do you explain important matters clearly?6. Does your assessment provide overall understanding of the user’s real-life situation and health conditions?7. Does your assessment cover the kind of life the user and his/her family wish to lead in the future? 8. Do you make sure the opinions from the Nursing Care Authorization Board and the family doctor? 9. Do you deicide the total policy for helping and the tasks or problems necessary to solve with the user and his/her family? 10. Do you carefully strive to solve problems with the user’s and family’s intention in mind? 11. Do you form a care plan including services other than Long-term Care Insurance and informal support, from a viewpoint of ensuring of taken user’s entire life? 12. Do you draw up a care plan that takes into sufficient consideration of the user’s ability to pay?13. Have you attended or held care conference?14. Do you form a care plan based on the results of your assessment and the care conference? 15. Do you confirm regularly whether the care services delivered are adequate for the user and his/her family? 16. Do you arrange so that the user or his/her family can contact you even in your absence?＊Care managers evaluate ‘yes’, ‘difficult to evaluate’, ‘no’

In order to prevent such a negative syndrome, supervisors should praise staff members’ work and accept staff members’ stress as well as arrange an adequate working environment and pay attention not to let employees shoulder too heavy a　 workload .

Actually, an important point of these three supervisory aspects is affected by settings where supervision is practiced and whether staff members are skilled or unskilled. If a person who is not a staff member’s superior supervises out of the staff member’s workplace, such supervisors do not have the authority to manage a staff member’s jobs or intervene with his/her agency. In this situation, the main aim of such outside supervision should be recognized as educational and supportive supervision rather than administrative. Unless staff members are very experienced and

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skilled, supervisors must only have to confirm and advise staff members’ work from an immediate the administrative supervisory position.

3.Program and procedures of the training program―Musashino City in 　 Tokyo-Outline of training program for care managementThe care manager training institute holds a committee meeting on the training program sixtimes a year. The users of this program are care managers employed in a care management agency that provides services to the citizens of Musashino City. as well as care management

Table 2 Items entered in the case submission sheet by a care manager①Care managers’ name②Years working as a care manager③Number of cases that the care manager currently handles④Care manager qualification i.e. nurse, certified social worker, certified care worker⑤Agency Name Agency address

Agency telephone number ⑥Date of submission⑦Theme of case i.e. how to support a user suffering from serious senile dementia⑧Reasons why you submitted this case a)I have confidence in treating this plan but would like to be reevaluated.b)I don’t have much confidence in managing this case, so I would appreciate some advice.c) I would like some direction because I don’t know how to develop a plan.d)Other( )⑨Problems you faced trouble while contriving this care plan (no limit to answer)⑩Matters on which you would like to receive advice (check as many as desired)　1. How to write documents

2. Assessment 3. Cooperation with medical staff

　4. How to cope with conditions when the user’ s and his ／her family’s intention differ

5. How to monitor 6. Sensing needs when user’s will are not clear7. Other ( Fell free to mention anything)

agencies in neighboring cities. However, the municipal government decided that those cases the committee evaluates in this program are only the citizens of Musashino City. The care management leaders and committees guided thirty-five care managers in 2004 (Musashino Welfare Public Company, 2005).

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Procedures and process in the program①Care managers submit care plans and other materials First, care managers who wish to have an evaluation and supervision apply to the municipal government and the care manager training institute at the end of the previous year. The care manager training institute assigns those applicants the times when each care manager can be siren an evaluation and supervision.

Next, each care manager submits his/her care plan and materials including sixteen self-evaluation items from toward their own care management work process (Table 1). The

Table3 　　　User’s evaluation Sheet 　on the care manager1. Does your care manager make a favorable impression on you?2. Did your care manager explain all about the Long-term Care Insurance system? 3. Does your care manager explain other type of services in addition to the Long-term Care Insurance system? 4. Does your care manager explain sufficiently methods to use these services?5. Does your care manager explain important matters clearly?6. Does your care manager understand about your entire life situation such as your and your caregiver’s conditions?7. Does your care manager make sure how you and your families hope to spend your lives? 8. Does your care manager form a care plan reflecting your family doctor’s instructions and advice? 9. Does your care manager decide on a total policy not only by himself/herself but also with you and your family? 10. Does your care manager strive to solve tasks considering your and your family’s wishes? 11. Does your care manager form a care plan, including services other than the Long-term Care Insurance system, such as unique services delivered by the municipal government and family support?12. Does your care manager form a care plan considering your ability to pay?13. Are you aware that your care manager holds/attends the care conference for you?14. Did your care manager design a care plan for that it is easy to understand and that encourage you and your family to live your life? 15. Does your care manager confirm you regularly whether care services are being delivered according to your care plan and whether the goals planned? 16. Has your care manager arranged so that you and your family in contact even when he/she is absent?*Users evaluate ‘yes’, ‘difficult to evaluate’, ‘no’

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Table 4 　　Evaluation Items( for the committee members)1 Assessment(1)Does this care manager understand the user’s life situation?2. Confirmation of user’s intention(1) Does this care plan understand how the user and their family hope to spend their lives？(2) Does this care plan receive the opinion from the Nursing Care Authorization Board, and the user’s family doctor? (3) Does this care plan aim to improve ADL and QOL?(4) Does this care plan deicide a total policy to help towards independence? 3 Definition of user’s needs, purpose of care, and resources to meet user’s needs(1) Does this care plan provide the user’s tasks to solve in his/her entire life situation?(2) Does the care manager establish long-term goals, short-term goals, a time span in which to specifically resolve each tasks? (3) Does care manager take measures to cope with the following?4 the weekly care plan(1) Does this weekly care plan show the services provided clearly?(2) Does this care plan take into consideration the user’s and their family’s living activity? 5 care conference(1) Is the purpose of the care conference clarified for the users and care staff members?(2) Is adequate a conclusion and all tasks have been reached in the care conference to share with all members of the care team? (3) Are items and topics discussed in the care conference clearly reported? (4) Does this care manager ask to members of the care team other than when he/she can hold a care conference?(5) Does this care manager ask care staff members who did not attend the care conference and get their adequate information and opinion for the user? 6 care management process(1) Is this record clearly written, as the formal record in the care management agency?(2) Does this care manager provide information to determine, when they form or modify this care plan?7 monitoring(1) Does this care manager visit the user once a month and monitor the user’s condition and needs at least once every three months? (2) Does this care plan reflect the outcome of this regular monitoring the user? (3) Does this care manager arrange the care management process record and devise a monitoring sheet?

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* The committee members evaluate by scoring 1-7 questions below as follows:1: need to make a major effort to improve 　2: need to make some effort to

improve3: acceptable 　　4: good 　　5: excellent

８ overall evaluation* The committee members give a summary of their advice

applying care managers also submit their concerns (Table2) to committees only after obtaining user’s consent to provide their personal information to the training institute and committee.

② Care management leaders’ interview with users and families Next, care management leaders employed in the care manager training institute visit users and their families to examine their conditions and to ask for an evaluation of their care managers. Then, care management leaders review sixteen evaluation items (table 3) and conduct interviews.

③Committee members’ evaluation and summarization by care management leadersCommittee members evaluate the care management process based on care plans and records as well as users’ evaluations and the self evaluation of the care management process from eight perspectives: 1) assessment.;2) confirmation of user’s intention; 3) definition of user’s needs, purpose of care, and resources to meet user’s needs; 4) weekly care plan; 5) care conference; 6) care management process; 7) monitoring; and ８ ) overall evaluation. Care management leaders summarize their evaluation.

④ Holding the committee meeting and transmission of results to care managersAt the committee meeting, committee members, care management leaders, administrator of the training institute, and public officers in the department of LTCI clarify points to improve and discuss evaluation of each care manager’s care plan and intervention. After this meeting care management leader discuss recommendations with each care manager and give advice concerning care planning and intervention with users and their families. Furthermore, care management leaders send care managers’ reactions to their evaluations and advice to committee members (Musashino-shi Care Manager Training Institute 2005).

4. Discussion: functions of this program（ １ ） Administrative supervision Administrative supervision aims to ensure the quality of services. Therefore, in order to make sure staff members achieve their roles and

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overcome deficiencies ,the evaluation of care managers’ performance is indispensable.

　 Previous care management studies in Japan are divided into several types. The first type is to clarify the actual work done by a care managers by time study (Agenosono and Baba 2002; Soeda et al 2005). The second type is care managers’ self evaluation regarding their achievement of care management procedures to as they go through each phase(Watabe 2002 ； Baba 2002; Ayabe and Okada 2002). The third type is the users’ evaluation of the value of care management procedures. In the third type of study, researchers investigate not only care management procedures but also examine relationships between those procedures and users’ satisfaction or complaints about care management (Okada 2003; Kikuchi and Yamanoi 2003; Tanaka 2005).

In the training and evaluation program practiced in Musashino City, evaluations are derived from four perspectives: 1) user’s evaluations 2) a care manager’s self evaluations 3) care management leader’s evaluation’s and 4) the committee members’ evaluations. Combining evaluation from plural perspectives can provide a multilateral evaluation. 　 Shimizu (1983) classified service evaluation into four dimensions of the services provided ; 1) invested resources; 2) process; 3) outcome, the effectiveness of the result and its impact; and 4) efficiency. 　 From the viewpoint of evaluation dimensions, in which this program’s evaluation items are a process of evaluation the users, care managers, and the committee members examine intervention process rather than outcomes evaluate such as satisfaction. 　

Yet, it is difficult to measure the validity of the evaluations by committee members because their evaluations may be affected by the care managers’ abilities to write care plans and records, referring to a user’s evaluation, the care manager’s own self-evaluation, and a care management leader’s interviews with users. In order to ascertain an individual care manager’s real work and to deepen mutual understanding, an additional method the committee members meeting with individual care managers directly, must be developed.

Further, we have to examine the validity of evaluation items (Table 4). We have modified the evaluation items with the committee’s input. Analyzing evaluation items will lead us to determine the validity of the evaluation items.

From the perspective of service quality assurance to residents, this program has enabled the municipal government, which is the LTCI insurer, to become involved with a care manager’s practice by understanding competency of care managers and informing citizens about the care management agencies attending this program. However, they limited users to those who lived in Musashino City as subjects of the evaluation.

Consequently, if care managers take charge of a few users and care managers recognize that those users did not present serious conditions

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requiring advice from the committee and care management leaders, a gap between the municipal government’s intention and care managers’ wishes could form. Although the numbers of municipalities that have started this training program are limited, the extension of such a training program for care managers is required in order to ensure and broaden quality care management.

Educational supervisionSome previous studies (Hata et al. 2000; Ayabe and Okada 2002; Ayabe

et al.2003) reported that staff members in community care support centers and care managers who attended lectures of care management did a much better job in their care management practice than those who did not attend the lectures.Giving practical advice based on user’s actual needs encourages care managers to master the principles and procedures of care management.

The results of a survey given to participants by care management leaders are as follows. The subjects were thirty-five care managers who participated in this program with thirty-one (rate of respondents 88.6%) respondents. They were asked to evaluate on a scale of 5 the general outcome. Twenty-two(71%)of the respondents evaluated ‘very useful’ and 9 (29%) respondents evaluated it as ‘useful’.

Furthermore, they asked the participants, ’what results did you obtain by presenting your cases for the training program?’ The largest number of respondents, twenty-four care managers, answered‘ I came to understood weak points that I had not notice’, twenty-one care managers said ‘ I understand now what I need to improve’, thirteen respondents said ‘ I got good advice about problems’, 6 respondents said ‘I developed self-confidence’s, and 2 respondents had no reply (Musashino Welfare Public Company 2005). In this training program, care managers indicated they wished to get feedback from the committee and care management leaders when they submitted cases to the institute. Many care managers did not notice their weak points in order to fix them by themselves. In order to recognize their own weak points, a certain level of experience and ability is required. Care management is a supportive process that consists of a series of procedures: intake, assessment, planning, service implementation, and monitoring. One procedure continuously connects with the other procedures. Forming a relationship with users in the intake process is involved in the gathering of information and analyzing tasks during the assessment. Similarly, gathering information and analyzing tasks in assessment is connected with setting a goal and identifying resources in planning. The ways that care managers recognize difficulties and seek advice are not separate but are related to each other. Therefore, the counsel that the committee members and care management leaders give must not only be about problems provided by the

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care managers but also must be concerned with the whole care management process. For example, if a care manager wishes advice about learning a user’s needs and setting a goal, the committee members and care management leaders often recognize that he/she does not gather information or analyze tasks well enough for those procedures. In such a case, the committee members and the care management leaders showed offer advice concerning these other matters in addition to the areas he/she provided. That might encourage care managers to deepen their understanding of their unconscious weak points by themselves. The advice given to care managers is limited by the fact that they do not meet with the committee members directly. Care management leaders do interview users and transmit back the committee members’ opinions to the care managers. Therefore, the committee members can not always confirm the details about which each care manager seeks advice and the interventions that he/she has performed without records. This process might create a gap between a care manager and the committee members. The committee members and care management leaders evaluate and instruct care manager’s intervention with only one user in this program. The care manager’s own effort decides whether this program will enhance his/her competency. In order to enhance the outcomes of this program, we have to examine that the knowledge and skill acquired in this program will contribute to a care manager’s performance.

Supportive supervisionAfter the enforcement of LTCI, many researchers have pointed out care management’s difficulties caused by vagueness of the work required, serious labor conditions, and the insufficiency of knowledge and skills (Matubara 2003; Yoshie and Kai 2004; Wake　 2004). 　 Yoshie and Kai （ 2004 ） 　 described that care manager’s colleagues, in other words ‘peer support’, is the most important support for care managers. Because it can be an information source or practical assistance to alleviate difficulties of care management work. Actually, it is difficult for care managers to share their difficulties with other care managers because many care management agencies employ only one care manager (Tokyo Metropolitan Institute of Gerontology 2004).1 　 Such lonely work conditions might increase a care manager’s psychological stress. When care management leaders contact each care manager and give 1Tokyo Metropolitan Institute of Gerontology, Report on investigation of care management in care management agencies in Tokyo Metropolitan, 2004. According to this report (subjects 600, respondents 259 response, 43.2%), agencies that employ ‘one full-time care manager’ are 79 agencies (32.5%) and agencies that employ ‘one full-time care manager or additional post care manager’ total 71 (29.2%).

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advice, care managers frequently talk with care management leaders about this distress as well as concrete problems about their work. That means care managers have few opportunities to share problems or receive advice. 　 In fact, this one-time instruction can not solve all difficulties and distress but needs also to provide continuous support for care managers. The care manager training institute delivers both a one-time training program and ongoing consultation. Consequently, it is possible for care managers to get regular help from care management leaders following this program. We are limited in discussing this supportive perspective because we have not completed a survey that includes items on the supportive functions. Therefore, we need to survey the outcome of the support functions and discuss methods to encourage and keep this continuous assistance after the initial program is over.

５ ． ImplicationThis program aims to enhance care managers’ knowledge and skills to deliver adequate services. In order to achieve this aim, we need to clarify the knowledge, skills, values and performance required for care managers grounded on the data these two-year 　 training programs. One method is to examine care managers’ performance achievements analyzing each evaluation item’s mean and standard deviation. This analysis will show us care managers working conditions and difficulties. Another method is to compare care managers using health and medical qualifications and welfare qualifications. Previous studies indicated that care managers did not have a common specialty and that work was influenced by their prior basic qualifications (Yamanoi et al. 2005). Searching for a common specialty for care managers, it is necessary for us to learn the different viewpoints from each profession and to make an effort to fill in the various knowledge and skill gaps. In this paper, I have examined this program from the viewpoint of the care manager’s intervention. However, if we consider this program also as a supervisory program, the aims of the program are not merely improvement and support for care managers but also to contribute to elevating the care service delivery system in an agency (Intaglia 1982 ） . In our program, there is the clear ability to improve care service delivery system in the community since this program is practiced under the municipal government’s oversight. If submitted care managers’ practical data let us know that a lack of social services creates obstacles to the achievement of care management, the municipal government must develop and future improve social services to alleviate these obstacles. Therefore, it is necessary to consider this program’s effect on constructing a social care services delivery system in the community.

ReferencesAgenosono, Y. and Baba, J.(2002) K-shi ni Okeru Kaigo Shien Senmonnin no

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Gyomu Jikan Chosa no Bunseki 　 〔 Analysis of Time Study of Care Managers’ Work in K City 〕 , The Extract of 50th National Conference, Japanese Association of Social Welfare, 370.

Ayabe.T. and Okada,N.(2002) Kaigo Shien Senmonnin no Gyomu zyono Yakuwari ni Taisuru Tasseido ni kannsuru Kenkyu 〔 A Study on the Achievement of Care Manager’s Role on the Job 〕 , Study Reports of Baika Junior College, No. 50, 75-86.

Ayabe.T.,Okada, S., Shirasawa.M. and Okada,N.(2003)Care management gyomu ni okeru kaigoshien senmonninin no kadai tasseido ni kansuru kenkyu, 〔 A Study on the Achievement of Care Manager’s Task on the Care Management Jobs 〕 , Journal of Health and Welfare Statistics,Vol.50, No. 2, 9-16.

Baba, J. (2002) Kaigo Shien Senmonin no Care Management Gyomu no Genzyo to Kadai 〔 How ‘the Japanese Care Managers’ work under the Long-term Care Insurance 〕 , Den-en Chohu University, Human Welfare Review, Vol. 5, 63-85.

Challis, D. and Davies, B. (1986) Case Management in Community Care, British Crown.

Clarkson, P. and Challis, D. (2003) Quality Assurance Practices in Care Management: A Perspective from the United Kingdom, Care Management Journals Vol. 4, No.3, 142-152.

Department of Welfare, Tokyo Metropolitan, Conference of Support for Care Managers in Tokyo (2004) Tokyo to Care Plan Hyoka Hyojun System no Katsuyo ni Kansuru Hokokusyo 〔 Report on Activation to Standardize Care Plan Evaluation in Tokyo Metropolitan 〕 .

Hata, C., Okada, S., Ozawa, A. and Shireasawa, M. (2000) Zaitaku Kaigo Shien Center no Care Management Zissen-Care Management Process ni Motozuita Ennzyo Kodo no Naiyo- 〔 Practice of care managers in a home-based care center-Care management process and its helping behaviors- 〕Japanese Journal of Gerontology, Vol.22 No.1, 59-71.

Ikegami, N. (2004) Opening Pandora’s Box: Making Long-term Care an Entitlement in Japan, Knapp, M., Challis, D., Fernandez, J., and Netten, A., Long-Term Care: Matching Resources and Needs, Ashgate, 129-140

Intaglia,J. (1982) Improving the Quality of Community Care for Chronically Mentally Disabled: The Role of Case Management, Schizophrenia Bulletin, Vol.8, No.4, 655-675.

Kadushin, A.and Harkness, D. (2002) Supervision in Social Work (4th edition), Columbia University Press.

Kamata, K. (2005) Kensyu dewa Jibuntachi ga Nobiteiko to Suru Shisei wo 〔 Care managers are required to be advanced by a Supervisory Training 〕 , Journal of Care management, Monthly, Vol. 6, No. 3, 13-15, Kankyo Shinbunsya.

Kikuchi,K. and Yamanoi,R.(2003) Care Management, Hiraoka, K., ed. The Evaluation Study on the Outcome of Reorganization of Care Service Provision System, 157-172.

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Kunimitsu, T. and Long-term Care Insurance Section, Department of Welfare and Health, Toyama City (2004) Chiikiryoku wo Takameru Toyama Akapen Hosihki:Care Managemento to Team Care 〔 Toyama Style Corrected by Red Pen to Enhance Community Power: Care management and Team Care 〕 , Tokyo: Nenyu Kikaku.

Long-Term Care Insurance Department, Office of Policy Promotion for the Elderly, Tokyo Metropolitan Government (2000) Long-Term Care Insurance System: Supporting Nursing Care thorough Society, Tokyo Metropolitan Government.

Musashino Welfare Public Company (2005) Report on the Training Program for Care Management: Musashino-shi care manager training institute.

Matubara, H.(2003) Kaigo Shien Senmonin no Hoyu Shikaku to Rodo Zyoken kara Mita Genzyo to Kadai 〔 Condtions and Tasks to examine by qualifications that care managers acquire and labor conditions 〕 , Yutakana Kurashi, No. 253, 11-16.

Musashino-shi Care Manager Training Institute (2005) The Manual of the Training Program for Care Management (third edition).

Okada, N. (2003) Kaigo Hoken no Kyotaku Service Riyosha no ‘Kuzyo’ ni Tuite no Kenkyu –Osaka shi ni okeru Chosa wo moto ni 　 〔 A Study of In-home Care Service User’s Compliant –based on investigation in Osaka City 〕 , The Bulletin of Otani Women’s University, No. 37, 95-114.

Rose,S.,ed.(1992) Case Management and Social work Practice, National Association of Social Workers.

Sandhna, D., Beger.C. and Ivy, C. (1996) Supervision and Quality Assurance in Long-term Care Case Management, Journal of Case Management,Vol. 5, No.3, 65-71.

Shimizu, Y.(2005), Koreisha Hoken Fukushi Service Hyouka Kenkyu no Doko to Kadai, 〔 The State of the art and future tasks in evaluation research of health and social services for the elderly in Japan 〕 , Japanese Journal of Gerontology, Vol.27, No. 1, 55-64..

Soeda, A. (1997) Zaitaku Kaigo Shien Center no Care Management 〔 Care management in Community Care Support Centers 〕 , Tokyo: Chuou Hoki Shuppan.

Soeda, A., ed. (2004) Kaigo Hoken ka no Zaitaku Kaigo Shien Center -Care Management to Social Work- 〔 Community Care Support Centers under Long-Term Care Insurance-Care management and Social Work- 〕 , Tokyo: Chuou Hoki Shuppan.

Someya, A. (2005) Care Manager no Shien Taisei wo Kyokasuru 〔 Empowering a Support System for Care Managers〕 , Gekkan Care Management 〔 Journal of Care management, Monthly 〕 Vol. 6 ,No. 3, 13-15, Kankyo Shinbunsya,25-27.

Tanaka ,C. (2005) Care Management wa ‘Riyosha Honi’ ni Okonawareteiruka 〔Is User-centered care management achieved? 〕 , Sugisawa, H., Nakatani, Y. and Sugihara, Y., eds. Kaigo Hoken Seido no Hyoka –Koreisha Kazoku no

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Shiten kara- 〔Evaluation of Long-Term Care Insurance-from perspective of the elderly and family- 〕, Sanwa Shoseki,127-140.

Tokyo Metropolitan Institute of Gerontology, Report on investigation of care management in care management agencies in Tokyo Metropolitan, 2004.

Yamanoi, R., Obuchi, T.and Toyama, T. (2005) A Study of Supervision for Care Staff, Meisei University,No.41,133-145.

Yoshie, S.and Kai, I. (2004) Kaigo Shien Sennmonin no Syokumu Suiko zyo no Konnan oyobi Shien Kensyu ni kansuru Tyosa Hokoku 〔 Report on Difficulties of Achievement of Care Manager’s Jobs and Support and Training for Care Managers 〕 . Tokyo University.

Wake, J.(2004) Kaigo Shien Sennmonin ni yoru Care Management-Sogai Yoin no Bunseki- 〔 Care management practice by care managers- Quantitative analysis of factor- 〕 , Tokyo Metropolitan University, Report on Human Studies 350, Social Welfare 20, 17-44.

Watabe, R.(2002) 　 Riyosya Shutai no Koreisha Care wo Meguru Kadai-Care Manager no Shigoto wo Toshite 　 Miru Riyosha Shutai Care no Arikata 〔 User-centered Long-term care; The care manager’s role〕 , Japanese Journal of Gerontology, Vol. 24, No. 1, 30-38.

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