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老健での医療、診療報酬から給付を提言－全老健

全老健は、このほどまとめた報告書「老健施設を『高齢者の生活を最後まで支援する』地域の拠点に」を説明。この中で、老健施設における医療の包括範囲を明確にし、それ以外は利用者の医療保険利用を認めるほか、老健を保険医療機関とし、施設で医療サービスを提供した場合、診療報酬の給付を可能にするよう提言している。
　また、老健における看取りが、今年度の介護報酬改定で「ターミナル加算」として評価されたことについて、将来的には医療保険からの給付が望ましいとしたほか、療養病床から転換した「介護療養型老人保健施設」が、機能面で既存の老健との違いが明確でなく、終末期の医療・ケアサービスの提供に対する評価を整理することによって、老健で二つの類型が存在する「ダブルスタンダード」の状況は解消されるとしている。

■4割が終末期医療を実施
　全老健はまた、昨年度の「老人保健施設における適切な医療提供のあり方に関する研究事業」の中間報告を行った。調査が今年2月に行われ、会員3300施設に調査票を発送し、1388施設から回答があった（回答率42.1％）。
　それによると、医師のオンコール体制がある老健施設は55.6％だったほか、併設の医療機関があるなど32.0％の施設で夜間対応が可能であるという。また、看護師が必ず当直する施設は78.0％だったほか、過去1年間に終末期医療を行った施設が41.1％に上ったという。看取りを行った施設の対応件数は平均で5件だった。
　老健施設で適切な医療行為をするための課題などを聞いたところ、医療保険の適用拡大についての意見が最多だった。この中では、老健が包括医療を行うことから、医療の抑制が働いたり、医療を提供すればするだけ赤字になったりするという意見が寄せられたという。
　また、眼科や耳鼻科など他科を受診する場合、利用者の自己負担分以外は施設の負担となる仕組みが、経営に重くのし掛かっているという。
　マンパワーの面では、医師や看護師、介護士がそれぞれ足りないという意見が出た。また、病状が不安定な利用者や重症化している利用者が従来に比べて増え、医療に対するニーズも大きくなっているほか、老健で医療行為をどこまで行うべきかという疑問もあったという。
　2010年や12年の診療報酬改定への要望として、抗がん剤注射製剤など高額な薬剤についての見直しや、介護職に経管栄養、喀痰吸引、インスリン皮下注射などの医療行為を認める要望もあったという（医療CBC)

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