The authors propose a dementia care special team consisting of six specialists below (nurse, rehabilitation specialist, MSW, pharmacist, dietitian, care worker).

Reason for choosing the six job: The arrangement standard of nursing professions, rehabilitation specialists and MSWs includes “full-time work”. Moreover, pharmacists and dietitians showed their wish to participate in wards for community-based care. Care workers are not only is adjacent to ADL but also capable of collecting information including the family and the patient’s back ground.

Functions and practice contents of the multi-job title cooperation

Base: The present situation and problems (19 categories)

Base: Actual situation of collaboration and cooperation by the multi-job titles (13 categories)

1. Family handling function (family) *Provide the family with an opportunity to learn dementia correctly *Explain that the patient is dementia spending time after description is given by the physician, *Have the family see the situation of ADL and treatment during the hospitalization *Confirm wishes about the medication management and explain changes one by one *Talk about the life after the discharge including the place where the patient is discharged to *Support the life of the family and the patient comprehensively

Treatment of both the main illness and dementia is needed Difficulty that the family has The family believes that the patient will be recovered The patient’s family cannot understand dementia without an opportunity

Respect for the patient’s ability and self-determination at home

2. ADL maintenance and improved function (dementia patient) *Grasp diet habit or internal use situation at the time of hospitalization and provide the ward with it. *Perform periodical assessment of ADL and share it among specialists *Reduce recumbency in the daytime and perform investigation not to have the patient be confined to bed *Regularly assess the influence of psychotropic drugs on diet and rehabilitation *For effect measurement of psychotropic drugs, examine dangerous behaviors by separating them by colors

Control such as suppression, medicine and diet is not performed well The patient’s food intake decreases under the influence of cognitive function degradation and medicine It is necessary to watch calorie intake The patient is re-hospitalized for being unable to do self-management Psychotropic drugs used from hospitalization exerts an influence on the patient’s life Worried for prescription Dilemma occurs for setting a limit to the patient’s behaviors I feel worried with the situation that the patient’s sleep hours in the daytime are long while results are demanded Cannot provide the cares that I want because of restriction in the duties time The dependence on specialist prevents cooperation

Investigation of the diet forms and the use oft food and medicine Investigation of place for diet, sitting position maintenance and tableware sizes Being able to arrange medicines at the time of hospitalization and information exchange with the specialists in the local community Investigation of medicine effects and medicine usage for the hospitalized patients Raise the patient’s activity by collaboration of rehabilitation specialists and nurses Consideration of specific support including transfer and portable restrooms Practice of observation of dangerous behaviors and care by the prediction Predischarge visit and observation rehabilitation of the local specialists

3. Staff member education and empowerment function (specialist) *Provide places where staff can learn new knowledge about dementia *Provide information on cares in the local community and at home particularly on characteristics of the place where the patient is discharged to *Respond to dangerous behaviors by tracking support *Examine time zones and places which dementia patients can be involved with each other safely *Examine in-hospital daycare and increase activity in the daytime *Tell the meaning of the empowerment to the dementia patient, their family and staff members *Invite the local specialists to an observation tour of rehabilitation and cooperate with them for discharge support

Dementia patient case harder than expected Dementia patients who are confused Stress by being unable to have place where the patient is discharged to The patient does not have money living alone, and there is not a network to support them in the local community Difficulty in returning home

Empowerment by multi-job titles Review of the patient’s livelihood time and investigation of their relation with others Need of tracking support and in-hospital daycare as staff member education Promotion of learning and workshop of dementia