ケアサポート９／ケアマネージャー（介護支援専門員）試験／ＴＯＰへ

厚生労働省は2月7日の社会保障審議会介護給付費分科会（分科会長＝大森彌・東大名誉教授）に、区分支給限度額に関する調査結果を示した。それによると、限度額を超えて利用している人のうち、2種類以下のサービスを使っている人の割合が全体の8割超を占めていた。

調査は、全国の市町村が、▽限度額を超えてサービスを利用している実例▽限度額の7－9割程度のサービスを利用している実例―のそれぞれについて、要支援・要介護度別に1人ずつを抽出し、介護支援専門員からヒアリングを行うなどして実施。厚労省が集計した。

　調査結果によると、限度額を超過した人が利用しているサービスの種類は、1種類が32.4％、2種類が52.6％、3種類が13.6％、4種類以上が1.4％と、2種類以下が85.0％を占めた。要介護度別に見ると、要介護1で92.2％が、要介護5で74.4％が2種類以下の利用だった。限度額に満たない人でも、2種類以下のサービス利用者が全体の86.1％で、超過利用者と同様の傾向にあった。
　サービスの種類を見ると、いずれも通所介護や訪問介護、短期入所サービスなどの介護系サービスに比べ、通所リハビリテーションや訪問看護といった医療系サービスの利用が少なかった。

■超過理由、「家族で介護補えない」が最多
　介護支援専門員に対し、限度額を超えたケアプランを作成した理由を複数回答で尋ねたところ、「家族などで介護が補えないため」が77.5％で最も多く、以下は「利用者本人や家族からの強い要望があるため」47.7％、「利用者の認知症が進行しており、多くのサービスが必要なため」38.2％、「利用者の状態像から判断して、多くのサービスが必要なため」36.7％などと続いた。「経済的に余裕があり、自己負担を気にしないため」は24.3％だった。
　また、訪問介護サービスの利用状況についての調査では、要介護度が低い利用者ほど生活援助の利用割合が高い傾向にあった。

■ケアプラン、9割超が「見直す余地あり」
　また今回の調査では、市町村でケアプランの点検や指導などを行う看護師2人と「社会福祉士・介護福祉士」2人の計4人が、一部の超過利用者の週間ケアプランの内容を評価した。それによると、見直す余地があると評価したケアプランの割合が9割を超えた。

■ケアマネジメントの在り方を批判―池田委員
　調査結果に関する意見交換では、池田省三委員（龍谷大教授）が、2種類以下のサービス利用が多い点について、「（ケアマネジメントが）サービスの組み合わせを考えておらず、家族の要求に言いなりになっている。ニーズとデマンドの区別が全く付いていない」と批判。「緊急にケアマネジメントの再構築を考えなければならない」と強調した。木村隆次委員（日本介護支援専門員協会会長）は、「この（示された）データで良い悪いは判断できない」とした上で、介護支援専門員資格の在り方などについて、抜本的に改革する必要があるとした。
　また、区分支給限度額に関して齊藤秀樹委員（全国老人クラブ連合会理事・事務局長）は、軽度者に生活援助サービスの利用が多いことを挙げ、「軽度の段階では自分ができない生活援助サービスを求めるが、重度になるとより緊急度のある身体介護に回さざるを得ないため、生活援助を削っている」と指摘した。
　このほか井部俊子委員（日本看護協会副会長）は、生活援助を必要とする独居高齢者らが必要な訪問看護を受けられない状況があると指摘し、「（区分支給）限度額の見直しや、訪問看護を医療保険適用にするなど、在宅療養を継続できる仕組みを検討する必要がある」と述べた。

　一方、週間ケアプランの評価結果については、「限られた時間や条件の中で（の調査であり）、これが独り歩きすることは好ましくない」「ケアプランが妥当かどうかは、対象者の個別的な事情も見なければいけない」などと、示されたデータの慎重な取り扱いを求める声が相次いだ。

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