「通院できなくなったら、どうすればいいのか」

外来でよく聞かれる言葉があります。「足腰が弱くなってきて、いつまで来られるか分からない」「親が外来受診できなくなってきたが、どうすればいいか」——そういう不安を抱えたまま、誰にも相談できずにいる方が少なくありません。外来に通えなくなっても、医療を続ける方法があります。

医師が定期的に自宅や施設を訪問して診察・処方・検査・療養指導を行う「在宅診療（訪問診療）」です。在宅診療は、急変したときだけ呼ぶ「往診」とは異なります。月に1〜2回、あるいは状態に応じた頻度で計画的に訪問し、病状を継続的に把握しながら管理する医療です。外来と同様に健康保険が適用されます。

こんな方に在宅診療をご検討ください

在宅診療の対象は、「寝たきりの方だけ」「末期がんの方だけ」ではありません。次のような状況であれば、在宅診療への移行を検討する価値があります。

一人では通院できず、毎回家族の付き添いが必要になってきた方。心不全・慢性閉塞性肺疾患（COPD）など、外出自体が体に負担になっている方。認知症が進み、待合室での長時間待機が難しくなってきた方。退院後に通院継続が難しくなり、自宅療養に移行した方。施設（有料老人ホーム・サービス付き高齢者向け住宅など）に入居しており、かかりつけ医が必要な方。「まだ歩けるから在宅診療は関係ない」と思っていても、少し状態が変わったときに慌てないよう、早めに相談しておくことをお勧めします。

在宅診療でできること

在宅診療では、外来と同様のことが自宅で受けられます。

【診察・処方の継続】定期的な診察のほか、血圧・体重・浮腫の確認、聴診など。慢性疾患の処方薬の管理・調整も行います。体調の変化に応じて薬の種類や量を細かく調整することも、在宅診療の重要な役割です。

【検査】血液検査・尿検査は自宅で採取・送付が可能です。心電図・簡易睡眠検査など、一部の検査は自宅で実施できます。

【急変時の対応】在宅診療を担当している医師は、担当患者さんの急変時に電話相談・往診で対応します。「何かあったときにどこに連絡すればいいか分からない」という不安を解消できます。

【入退院の調整・多職種連携】状態が悪化した際の入院調整や、退院後の在宅復帰支援も行います。訪問看護師・ケアマネジャー・薬剤師・リハビリスタッフなど、関わるすべての職種と連携して患者さんの療養を支えます。

医療ソーシャルワーカーが、療養の全体を支えます

在宅診療を始めるにあたって、医療的な管理だけでなく、介護サービスの調整・住環境の整備・家族への支援など、様々な課題が出てくることがあります。「何から手をつければいいか分からない」という方がほとんどです。

岡田内科には、医療ソーシャルワーカー（MSW）が常駐しています。MSWは、患者さんやご家族が抱える生活上・社会的な課題に対して、専門的な立場から支援を行う職種です。介護保険の申請・更新・区分変更の相談。ケアマネジャーや訪問看護ステーションとの連携調整。退院後に自宅療養へ移行する際の手続きサポート。経済的な問題や家族の介護負担に関する相談。施設入所の検討・紹介——こうした幅広い内容をお手伝いします。

医師が医療を担当し、MSWが生活・福祉の調整を担う。この連携によって、患者さんが安心して自宅で療養を続けられる体制を整えることができます。「何をどこに相談すればいいかわからない」という状況でも、まず岡田内科にご連絡いただければ、MSWが状況を整理してお手伝いします。

岡田内科の在宅診療の特徴

岡田内科では、循環器内科専門医と糖尿病内科専門医が在宅診療を担当しています。心不全・不整脈・高血圧・糖尿病・睡眠時無呼吸症候群（SAS）・慢性腎臓病など、専門的な管理が必要な疾患を抱えながら自宅で療養されている方に、外来と変わらない医療を提供します。

また、CPAP（持続陽圧呼吸療法）・在宅酸素療法（HOT）・非侵襲的陽圧換気療法（NIPPV）を使用されている方も、在宅診療の中で継続管理が可能です。訪問エリアは長野市内を中心としています。ご本人・ご家族どちらからのご相談も歓迎します。まずはお気軽にお電話ください。

ご相談やお問い合わせは、お電話・受付窓口にて承っております。
詳しくは、在宅診療のページをご覧ください。

大林賢史
Kenji Obayashi, MD, PhD
　医師の研究者プロフィールはこちら

　
　
　
　
　
　
　

What Is Home Medical Care? — Even When You Can No Longer Visit the Clinic, Your Care Can Continue

“What should I do if I can no longer come in for appointments?”

There are words we often hear in our outpatient clinic. “My legs and back have grown weaker, and I’m not sure how much longer I’ll be able to come in.” “My parent is becoming unable to attend outpatient appointments—what should we do?” Many people carry these worries without anyone to turn to for advice.

Even when you can no longer visit the clinic in person, there is a way to continue receiving medical care. It is called home medical care (home-visit medical care), in which a physician regularly visits your home or care facility to provide examinations, prescriptions, testing, and guidance on managing your condition. Home medical care is different from a “house call” (ōshin), which is requested only when there is a sudden change in condition. Home medical care involves planned visits—once or twice a month, or at a frequency suited to your condition—through which your physician continuously monitors and manages your health. Because health insurance applies just as it does for outpatient care, the patient’s out-of-pocket cost is largely the same as for an outpatient visit.

Who Should Consider Home Medical Care

Home medical care is not only for “people who are bedridden” or “people with terminal cancer.” If any of the following situations apply, it may be worth considering a transition to home medical care.

Those who can no longer travel to the clinic alone and now need a family member to accompany them every time. Those whose conditions—such as heart failure or chronic obstructive pulmonary disease (COPD)—make going out itself a strain on the body. Those whose dementia has progressed, making it difficult to wait for long periods in a waiting room. Those who have found it hard to continue outpatient visits after being discharged from the hospital and have moved to recuperating at home. And those living in a facility (such as a fee-based nursing home or a service-supported housing for the elderly) who need a primary care physician.

Even if you think, “I can still walk, so home medical care doesn’t apply to me,” we encourage you to consult with us early—so that you won’t be caught off guard if your condition changes even slightly.

What Home Medical Care Can Do

With home medical care, you can receive at home much of what you would receive at the outpatient clinic.

Continued examination and prescription. In addition to regular examinations, this includes checking blood pressure, weight, and edema, as well as auscultation. We also manage and adjust prescription medications for chronic conditions. Finely adjusting the type and dosage of medication in response to changes in your condition is an important part of home medical care.

Testing. Blood and urine samples can be collected at home and sent for analysis. Some tests, such as electrocardiograms (ECG) and simplified sleep studies, can be performed at home.

Response to sudden changes in condition. The physician in charge of your home medical care responds to any sudden change in a patient’s condition through telephone consultation or a house call. This relieves the worry of “not knowing who to contact when something happens.”

Coordination of hospital admission and discharge, and multidisciplinary collaboration. We arrange hospital admission when a condition worsens and support the return home after discharge. We work together with all the professionals involved in your care—visiting nurses, care managers, visiting pharmacists, rehabilitation staff, and others—to support your recuperation.

A Medical Social Worker Supports Your Care as a Whole

When beginning home medical care, various challenges can arise beyond medical management alone—coordinating nursing-care services, preparing the living environment, and supporting the family. Most people feel, “I don’t even know where to begin.”

At Okada Internal Medicine Clinic, a medical social worker (MSW) is on staff full-time. An MSW is a professional who provides expert support for the everyday and social challenges that patients and their families face. This includes consultation on applying for, renewing, or changing the classification of long-term care insurance; coordination with care managers and visiting-nursing stations; support with the procedures involved in transitioning to home recuperation after discharge; consultation regarding financial concerns or the family’s caregiving burden; and consideration of, and referral to, facility admission. We help with this wide range of matters.

The physician handles medical care, and the MSW handles the coordination of daily life and welfare services. Through this collaboration, we can build a structure in which patients can continue to recuperate at home with peace of mind. Even if you find yourself thinking, “I don’t know what to ask, or who to ask,” please first contact Okada Internal Medicine Clinic, and our MSW will help you organize your situation.

Features of Home Medical Care at Okada Clinic

At Okada Clinic, home medical care is provided by a board-certified cardiologist and a board-certified diabetologist. We offer the same standard of care as our outpatient clinic to those recuperating at home while managing conditions that require specialized care—such as heart failure, arrhythmia, hypertension, diabetes, sleep apnea syndrome (SAS), and chronic kidney disease.

In addition, those using CPAP (continuous positive airway pressure therapy), home oxygen therapy (HOT), or NIPPV (non-invasive positive pressure ventilation) can continue to receive ongoing management as part of their home medical care. Our visiting area centers on the city of Nagano. We welcome inquiries from patients and family members alike. Please feel free to give us a call.

　

　

　

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