[Special Feature: Thinking about "Home Care"] The Visiting Nursing Business as a Business

There are currently about 10,000 visiting nursing offices, which calculates to one office for every 12,000 people. As shown in the figure on the next page, market growth can be divided into three periods: the creation period starting in FY1993, the stagnation period starting in FY2000, and the growth period starting in FY2011. While many industries are seeing market shrinkage in an era of population decline, the visiting nursing business is growing. Furthermore, the Japanese Nursing Association aims to have twice as many visiting nurses working by 2015.

The management entities of visiting nursing businesses include large corporations, medical corporations, and corporations established by individual nurses; some companies have even gone public through their visiting nursing business. While joint-stock companies cannot directly manage hospitals, they can manage visiting nursing services. While services like home-based caregiving can only use long-term care insurance, visiting nursing can also use medical insurance because it includes children requiring medical care and patients with young-onset mental illness or cancer. The government is utilizing market forces to the extent that it allows joint-stock companies to operate services that can use medical insurance. The number of elderly people will peak between 2042 and 2060, and the market will mature over the next 20 to 30 years, so investing now with a medium- to long-term strategy is required.

There are 600,000 monthly users of visiting nursing. Roughly speaking, the basic structure is five visits per month, one hour per visit, at a cost of 10,000 yen (with the individual paying 1,000 to 3,000 yen), and the market size is approximately 360 billion yen. There are six full-time equivalent nursing staff per visiting nursing office, and sales per person are approximately 6 million yen. Depending on the operator, sales per person can exceed 10 million yen. While a nurse in a rural area might make three visits a day with a one-hour one-way drive, a nurse in the city center might make six visits a day with a 10-minute one-way bicycle ride.

Every business has a pioneer. In the case of visiting nursing, it is a person named Shizuko Muramatsu. I heard Ms. Muramatsu's lecture in a class during my first year at the Faculty of Nursing and Medical Care. When Ms. Muramatsu began providing visiting nursing as a volunteer for patients being discharged from the hospital, people eventually emerged who were willing to pay out of pocket. When Ms. Muramatsu started visiting nursing for a fee, she was criticized by the nursing community for "turning nursing into a business." Nevertheless, Ms. Muramatsu proceeded with the commercialization of visiting nursing based on her conviction that nursing needs to respond to patient needs.

The government also took notice of this, investigated the service content provided by Ms. Muramatsu and others, and the system was developed so that public insurance could be used. Today, few people know who created visiting nursing, but in any business, we must not forget to respect the person who first dug the well.

In recent years, the market environment has changed, and demand for children requiring medical care, patients with mental illness, and terminal cancer patients is increasing. In particular, amid constraints on social security financial resources, the number of people being discharged from hospitals is increasing, and there is a growing demand for home-based care. Because of the high medical costs of end-of-life care in hospitals and the fact that citizens wish to spend their final days in their familiar homes, "home-based end-of-life care" at home or in nursing homes is being promoted. For these reasons, we need to spend the next 10 to 20 years creating the next generation of the visiting nursing business.

Public funds for visiting nursing are derived from taxes and social insurance premiums, and unnecessary services cannot be provided. Therefore, it is necessary to identify and provide the content and amount of service that is necessary and sufficient for the user. And, if possible, it is desirable for the user to become independent to the point where visiting nursing is no longer necessary and to end the use of the service. Under the current medical and long-term care fee schedules, there is no clear performance-based compensation system, but providing high-quality services leads to gaining the trust of users, families, partner medical institutions, and care managers. Furthermore, it becomes a source of professional pride for the staff who work there.

I graduated from the Faculty of Nursing and Medical Care in March 2005, and after working at a management consulting firm and a university hospital, I started "CarePro" in December 2007. Initially, we expanded from a preventive medical service called "One-Coin Health Checkups."

Then, through volunteering after the Great East Japan Earthquake on March 11, 2011, I faced the problem of "end-of-life refugees" dying in isolation, and I thought this might be a microcosm of Japan in a society with a high number of elderly deaths. If home-based medical care does not become widespread, isolated deaths will increase. It was estimated that there would be 300,000 end-of-life refugees in 2020, and assuming one visiting nurse cares for 10 people a year at the end of their lives, it was necessary to increase the number of nurses by 30,000. Therefore, I entered the visiting nursing business with the ambition of increasing the number of visiting nurses and preventing isolated deaths.

Analyzing the visiting nursing industry, it was characterized by an average nurse age of 47, which is more than 10 years higher than in hospitals. Because nurses visit patients with various diseases and disabilities—such as pediatric, psychiatric, or cancer patients—alone, experience and skills are required, and the common wisdom was that it was difficult for anyone other than a veteran.

On the other hand, while 55,000 new graduate nurses are produced every year, it also became clear that 19.6% are interested in community medicine, such as visiting nursing, at some point. As nursing education curricula at universities and nursing schools evolved, visiting nursing practicums became widespread, and many students became interested. However, the visiting nursing agencies that would receive them do not have education programs or budgets, so they do not accept new graduate nurses. In other words, the structure was one of "procuring" nurses who had been trained at hospitals.

However, in any industry, to become independent as an industry, it is required to procure human resources—the most important management resource—internally. Therefore, our company worked on training new graduate visiting nurses, thinking that if the number of new graduate or rookie visiting nurses increased by three at each of the 10,000 visiting nursing offices nationwide, the number of visiting nurses would increase by 30,000 nationwide, leading to the prevention of end-of-life refugees.

I have heard that when Toyota first made four-wheeled automobiles, they were laughed at by Western countries, but with the support of the Japanese government, the Japanese automobile industry grew significantly and began to earn foreign currency. Regarding the training of visiting nursing human resources, it was necessary to create know-how that could train them from scratch.

Therefore, CarePro began hiring new graduates in 2013 and has trained 12 to date. We invest 3 million yen per person to train them into full-fledged professionals. They go on about three accompanied visits a day with a senior colleague, gradually becoming able to make solo visits. When they start doing night shifts, there is a possibility of receiving calls from among more than 100 patients, so they need the ability to respond to patients with various diseases and conditions. Together with nurses who specialized in education at graduate school, we compiled our internal know-how and even published it as a textbook.

Until then, hiring and training new graduate visiting nurses was considered a taboo, but together with St. Luke's International University and the National Association for Visiting Nurse Service, we created training guidelines for new graduate visiting nurses and held seminars for visiting nursing agencies nationwide.

As a result, while only about 20 new graduate visiting nurses were hired annually nationwide in 2013, more than 300 were hired in 2019. By becoming able to hire new graduate visiting nurses, the hiring of experienced visiting nurses with fewer years of experience is also progressing. The Ministry of Health, Labour and Welfare and local governments have also begun to provide education subsidies to agencies that hire nurses performing visiting nursing for the first time.

Visiting nursing is a public insurance service, and the price is fixed. In a normal business, one can take a price strategy of "low quality but low price, high quality but high price," but because it is a regulated price, variations in quality tend to occur despite being the same price.

What recent visiting nursing users demand are things like "responding 24 hours a day when something happens" and "responding even if symptoms become severe." Our company has 50 staff members in the visiting nursing business and is large in scale, so we can respond to the diverse needs of users, to the point where we have had to turn some away. In the future, the visualization of the quality of operators will progress, and we will enter an era where they are chosen.

Also, currently, many offices have about five nurses, and 10 is considered large-scale. Large-scale offices find it easier to provide 24-hour support, and having staff with diverse expertise makes it easier to guarantee quality, leading to many profitable operations. However, the success factor for making an office large-scale is having multiple management positions, and there is a limit for sole proprietors who manage with a single manager or owner. Therefore, there is a demand for corporatization. Our company also receives consultations regarding scale expansion and M&A, and in the midst of fierce competition, a strategy for survival is required.

Visiting nursing under public insurance can provide services to the home, but it does not respond to needs such as wanting someone to accompany them on trips, shopping, hospital visits, commuting, or ceremonial occasions. Therefore, those who wish to have a nurse accompany them for travel, shopping, etc., must bear the full cost themselves. At our company, we have had requests for outing support from Akiyuki Nosaka, and I learned that there are many people who want to go out freely while having illnesses or disabilities.

On the other hand, there are many people who cannot easily pay 10,000 yen per hour, and there is a situation where a new business related to outing support that is simple and yet guarantees quality is required.

Our company is developing a reservation system that directly matches people who need mobility assistance with nurses and others. Immediately after launching the service, we received a request from a Japanese person living in New York for outing support for their mother living alone in Japan. Amid a shortage of healthcare human resources, I think it would be good if nurses and helpers across Japan could do side jobs in their spare time to provide mobility support based on the concept of the sharing economy. By taking on work as an individual, the price can be kept down to about 3,000 yen per hour.

Keio does not perform visiting nursing, but there are some school corporations that have entered the visiting nursing business. Also, within the Keio Gijuku Shachu, there are likely expectations for visiting nursing services provided by Keio or Keio graduates. Many patients at Keio Hospital also use visiting nursing, and the effect of "Mita-hyoron (official monthly journal published by Keio University Press)" will likely increase the need further. As an individual author, I would like to contribute in my own small way to Keio leading society in visiting nursing as well.