[Development of a community care system for patients with amyotrophic lateral sclerosis in the Hiroshima Bihoku region].

To understand the various problems of medical treatment and home care of ALS patients, we analyzed 23 ALS patients who live in the Bihoku region of Hiroshima prefecture. The ages of patients ranged from 50 to 88 years old. One patient was controlled with mechanical ventilation. The patients and their families utilized available home health care services well. A care manager managed to find appropriate resources for the patients as the disease progressed. Although limited in resources, patients' friends and neighbors offered an informal community support. An early approval of support enabled the patient to initiate home care. The incidence of hospitalization due to social reasons was higher in patients without communication to a care manager or without well cooperative support. Assessments of patient and family needs are important for a development of a community care system. It is also essential for all of the patients to have a good cooperative relationship.