How to Read Your Parent's Japanese Care Plan (Kyotaku Plan) in English

Kyotaku Kaigo Shien: Home Care Support and Its Paperwork

A Japanese care plan is a bundled set of standard government forms, not a single page, and each form answers a different question.

When people say "my parent's care plan," they usually mean the kyotaku service keikaku (居宅サービス計画), the plan a care manager drafts under Japan's long-term care insurance system for someone living at home. It is produced by a kyotaku kaigo shien jigyosho, a home care support office, and it is separate from the care manager as a person. For background on that role, see what a care manager in Japan actually does for a foreign family; this article is about the paper the care manager hands over, not the person who writes it.

The plan is issued as a set of standard forms defined by the Ministry of Health, Labour and Welfare (MHLW), numbered Table 1 through Table 7. Care managers are required to explain the plan to the person and family and to deliver a copy once it is finalized. If your parent or the care manager only ever mentions "the plan" as one folded printout, ask specifically which numbered table you are looking at; families abroad often end up with a photo of Table 1 and nothing else, which answers almost none of the practical questions.

Two forms cover intent and structure, two cover goals and schedule, and three cover the money and the process log. Knowing which table to ask for saves a round of confused messages between the family, the care manager, and the local Long-Term Care Insurance office.

Dai Ikkyo Through Dai Nanahyo: The Seven Forms at a Glance

Each numbered table has one job, and only two of the seven are worth reading closely from overseas.

• Table 2 is where you check whether a stated concern (for example, falls at night) actually has a matching service attached to it.
• Table 6 and Table 7 are the ones to open first if a bill looks different from last month.
• Table 5 is the record to request if you suspect your parent's concerns were never logged or followed up.

Assessment to Draft: How the Plan Gets Built

The plan is not written from a form alone; it comes from a face-to-face assessment, a set of stated goals, and a coordination meeting with the providers who will deliver each service.

The care manager starts with a needs assessment, using a standardized set of items covering daily living, mobility, cognition, and family support. From that assessment, Table 1 records what your parent and family said they want, and Table 2 turns each identified problem into a short-term and long-term goal with a named service attached. This is why a plan that only lists services without matching goals is worth questioning; the standard format requires the goal-to-service link to exist on Table 2.

Before the plan is finalized, the care manager is expected to hold a service tanto-sha kaigi, a meeting with the actual providers (the home helper agency, the day service, the visiting nurse) to confirm the plan is workable. Table 4 is the summary of what was agreed at that meeting. If your parent's plan changed after a hospital stay, this is the meeting where a revised approach gets set, and it connects directly to what happens at hospital discharge in Japan if a stay is involved.

Building the care team behind the plan, not just the document, matters when your family does not speak Japanese day to day; see building a bilingual care team in Japan for how families arrange English-capable contacts around this same care manager relationship.

Kyufu Kanri: Why the Plan Is Tied to a Monthly Limit

Every service on the plan draws against a fixed monthly benefit limit set by care-need level, and the care manager's job includes keeping the plan inside that limit.

Long-term care insurance sets a category-based benefit limit (kubun shikyu gendo kijun-gaku) for each care-need level, expressed in points (tan-i) rather than yen. As one example, a municipal reference for 2024 puts the limit at around 16,765 points a month at care-need level 1 and around 36,217 points a month at care-need level 5, with roughly ¥10 to ¥11.40 per point depending on the region and service type (see Source Links). The exact figure varies by municipality and by which services count toward the limit, so treat any number your family hears as an approximate range to confirm locally rather than a fixed national price.

Anything scheduled inside that monthly limit is generally covered at 90 percent (with 70 to 80 percent for higher-income households), and anything over the limit is billed in full. This is the arithmetic Table 6 and Table 7 are showing you. For the wider cost picture beyond this one monthly limit, including facility costs and out-of-pocket services, see the cost of elderly care in Japan for families abroad.

If your family is paying bills directly and a total suddenly looks higher, checking whether a new service pushed the plan past the monthly limit is a faster diagnosis than assuming an error, though asking the care manager to confirm is still the right next step.

Dai Rokuhyo and Dai Nanahyo: The Schedule and the Bill

Table 6 and Table 7 are the two forms that reveal whether the plan on paper matches the care your parent is actually receiving.

Table 6 lists, day by day for the month, which service is scheduled and how many units it uses. Table 7 turns those units into cost: the benefit amount insurance covers and the remainder your parent pays. If a service your parent mentioned on a phone call, such as an extra bath assistance visit, does not appear anywhere on Table 6, that is a concrete, specific thing to raise with the care manager rather than a vague "is everything okay" check-in.

These two forms are also the ones used for kyufu kanri, the monthly benefit management process that reconciles what was scheduled against what was billed. Mismatches between what your parent describes and what Table 6 shows are usually clerical (a cancelled visit, a substitute worker) rather than sinister, but they are worth resolving the same month, since providers correct billing records more easily before the month closes.

If your family is also managing payments and remittances across borders, cross-checking Table 7 against the actual invoice matters even more; see managing an elderly parent's finances in Japan from overseas for how families structure that oversight.

Monitaringu: What the Monthly Report Should Tell You

A care manager is required to visit and record a monitoring report at least once a month, and a report that reads identically to last month's is a signal worth following up on, not a sign that nothing needs your attention.

Under the operating standards for home care support offices, a care manager must meet the person at home and record a monitoring result at least once a month, absent special circumstances, and keep that record for two years. A 2024 revision allows part of this monitoring to happen by video call, but even then a home visit is still required at least once every two months. If your parent's care manager has moved to video-only check-ins, it is reasonable to ask which months included an actual home visit.

Monitoring reports commonly cover whether services are being used as planned, whether the person's condition has changed, and whether goals from Table 2 are still realistic. A short or repetitive monitoring note is not automatically a problem, since some months genuinely are stable, but it is worth asking the care manager directly whether anything changed rather than assuming stability from a thin report.

For families trying to interpret subtler shifts between visits, such as changes noticed only over video calls, this monitoring rhythm is a useful anchor: whatever your parent tells you between visits, the monitoring report is the place that change should eventually surface on paper.

Requesting a Copy and a Translation

Families abroad are entitled to see the full plan, and asking for a specific numbered table by name gets a faster, more complete answer than asking for "the care plan."

Care managers are required to deliver a copy of the finalized plan and explain its content, and there is no rule against requesting scanned copies of all seven tables rather than a summary. If your family cannot read Japanese day to day, asking the care manager's office whether they can provide an English summary alongside the Japanese original, even informally, is a reasonable request; not every office will say yes, but many will point you toward Table 2 and Table 6 specifically, since those two answer most of what an overseas family actually wants to know.

Legal authority to formally request or approve changes to a plan generally sits with your parent, or with whoever holds documented authority to act for them. If your parent's ability to review and approve plan changes is becoming uncertain, that question connects to power of attorney and legal authority for an aging parent in Japan, which covers how that authority is documented ahead of time.

Keep a simple family-side log of which tables you have seen and when. Because Table 5 already logs every contact between your parent and the care manager, your own short log mainly needs to note dates you reviewed Table 2 and Table 6, so a gap becomes obvious at a glance rather than something you have to reconstruct from memory during a crisis.

Service Tanto-sha Kaigi: Joining the Coordination Meeting Remotely

The meeting where the plan gets finalized is a realistic point for an overseas family member to join by phone or video, and doing so once a year is often more useful than trying to review every monthly form in detail.

The service tanto-sha kaigi, the meeting that produces Table 4, brings together the care manager and the providers named in Table 2. It typically happens when the plan is first created, at renewal of the care-need certification, or after a significant change such as a hospital stay. Asking in advance whether you can join by phone for even fifteen minutes, specifically to hear the goals restated in plain language, is a targeted request most care managers can accommodate with notice.

If, after reading the plan, something looks wrong (a goal on Table 2 with no matching service, a Table 6 entry your parent disputes, a monitoring report that has not changed in months) the direct step is to ask the care manager for a plan review, which any listed goal not being met can justify. This is a normal, expected request rather than a confrontational one, and it usually results in either a revised plan or a clear explanation of why the current one still fits.

Generally, how quickly a plan can be revised varies by office workload and by whether the change requires a new service tanto-sha kaigi, so treat "we'll update it" as the start of a process to follow up on rather than a completed action.