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In the community For the community By the community

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1 In the community For the community By the community
Home Care for elderly Indonesia; a new challenge in community managed healthcare In the community For the community By the community Attention: I speak about managed, most of the time people say community based, but I prefer managed, used by government and meaning you are active. In, for, by the community Buying a house: location location location Services: people, people, people

2 Presentation by Lenny van Ameijde, M.A.
Master of Arts (social science), Master International Service Management Director SerVision International: healthcare; tourism and hospitality; education Dissertation Semarang, Undip, Dr. Kariady Hospital “Empowerment of Indonesian nurses and quality of care, A Patient perspective” (2007) Earlier experience in Indonesie with UI, project specialised nurses and Univ Diponegoro, I don’t know if there are nurses from Dr. Kariady Hospital Semarang here, a nice stay, people were very much research minded.

3 Home care for elderly Indonesia:
a new challenge in community managed healthcare Considerations home care for the elderly Ageing society Indonesia Development home care in The Netherlands Development home care in Indonesia Strategy for the future Competencies home care nurse Commitment Education Recommendations Pilot Bali Preconditions implementation home care This is the line of my presentation, I will discuss different aspects of home care.

4 1. Considerations home care elderly
Ageing society Responsibility of society Criterion for quality of life in society Be active, be pro-active If no action, the elderly will feel neglected, isolated and lonesome. If we do not take care for the elderly in the last phase of their life, it means we have no respect for life. If you just wait and see, it is too late, if you are pro-active, you are prepared for the ageing society, and there will be not such a gap between needs of elderly and service provided

5 The rapidly ageing society: ARE YOU READY?
We are on the edge of the rapidly ageing society and the question we have to answer: are we ready

6 2. Ageing Society Indonesia
Double Ageing Less young people, so relatively more elderly people The elderly become older because of better health care Between 1950 and 2050 the elderly population will quadruple. Indonesia Population 60+ 80+ 2011 230 million 8.5% 0.5% 2050 300 million 25% 4.5% Density 114 people per square km 8,5 % = 20 million 25%= 75 million 80+ from more than 1 million to around 15 million, which is almost the entire population of The Netherlands Source: Undesa, United Nations department for economic and social affairs 2006

7 Facts & figures Indonesia
More elderly women than elderly men Higher proportion of women is widow Illiteracy rates older women are higher Family planning: less children especially among poor (2.4) Migration of young people to the city looking for a better life while elderly stay in rural area Elderly more dependent on community than on family Majority of elderly has low income/status, depends on others (family, government, charities) Just in a nutshell

8 Home care based upon specific needs elderly
Chronic diseases often lead to social problems. isolation anxiety loneliness depression diabetes bowel problems (incontinence)  dementia cancer Health problems Social problems Home care consists of a social and a health component. In practice these two components are linked with each other. The older the elderly population gets, the more chance of one or more chronic diseases. In case of more chronic diseases the care becomes complex.

9 CARE LADDER The Netherlands
Home care volunteer Day care Short stay Home for elderly professional Connected senior apartments Residence care compound In-house Small-scale living Continuum of care Costs Level of dependence Community care Institutional care Difficulties Homebound Assisted living Bedridden Nursing home First an overview of the continuum of care, illustrated as a ladder. You will see, as the level of dependence rises, also the costs rise. Small scale living people with dementia, sickness of Alzheimer, small living units attached to a central hall, as close as possible to a homely situation Homely interior design has positive influence on people

10 New concept: self-managing home care teams
A small decentralized organisation; the central office is just supporting (salary, training, administration) Client centred, cost effective (30% decrease), custom-made care (client satisfaction 9.1) Self-steering home care teams of 8-12 nurses/care assistants. 1 Coach for the teams in each district Few managers, more professionals (low overhead, flexible, cheap, effective) The use of ‘smart’ ICT: home care web and digital community Why do I use the word client centred instead of patient centred? Because the use of the word implies that the elderly is treated with respect, as a client who can expect the best care possible, adapted to his or her situation and wishes. A patient is more dependent, has to be ‘patient’…

11 Self-managing home care team
Characteristics Self-managing home care team Team of registred S1 and D3 nurses, community nurses level V and care assistants level 3 Team is self-managing, divides tasks among each other, makes own planning, asks other nurses to join team if necessary, so low overhead costs. 24 hours available on-call Elderly clients always are visited by the same nurse The care is client centred, not task centred, holistic: the nurse will do all the care for the client and tries to stimulate independence

12 Tasks self-managing home care team
Basic care and specialised nursing care Bathing, hair washing, shaving, grooming, dressing On request of general practitioner or specialist (insulin) injections, take care of wounds, pain reduction Medication prompting Communicating for client with other caregivers Coaching family members Dementia care support Terminal care

13 Network self-managing home care team
Interdependent Team works in close cooperation and direct contact with general practitioner and healthcare organisations Transfer nurses from hospitals, general practitioners, other health care organisations and private people refer elderly to home care team. Team gives guidance and is intermediary between client and doctor or other healthcare professionals. Has knowledge of specific community Team stays involved also if the elder needs hospital care Team has a small office in the community

14 Self-managing home care teams
Continuing training Self-managing home care teams The central office provides a budget for ongoing training, on request of the home care teams Individual training Team training The training can be in cooperation with a hospital about how to handle new equipment or provided in the skills lab of the nursing schools, or even provided by another home care team

15 4. Developent Home care Indonesia
Healthy Indonesia 2010 – strategy for national health development: In this document community managed healthcare and decentralization are promoted, and should be in operation in Few initiatives have been taken, such as Pusaka in Jakarta. The government policy has not succeeded as a consistent policy, absolutely insufficient to match the needs of the elderly. At this moment care for elderly (home care) is again on the political agenda.

16 Why community managed home care Indonesia
Less expensive than institutionalised care, more cost effective because it covers more elderly. Elderly can stay in their own community which creates self reliance and a sense of solidarity within communities. Home care is the right thing to do, because elderly are reluctant to leave their homes and relatives feel ashamed to send their parents to a home for elderly.

17 PUSAKA concept Indonesia
Pusat SAntunan dalam KeluargA means ‘Home-based Care Centre’. Pusaka also means ‘old and respected’. Concentrates on the first phase of home care, mainly the social component. In community, near the people: people go to the pusaka post Support provided by family and volunteers from neighbourhood Services consist of activities such as meals, repair and cleanliness of the house and water Income generating activities such as courses handicraft, cooking, and small grants Some Pusaka centers also provide basic health care for the elderly by establishing a Posyandu Lansia (Health Post for the Elderly). One of the few initiatives of home care. This is a good initiative for the first phase as shown in the care ladder. But what if health is no longer good, then elderly move to the second phase and need professional health care.

18 5. Strategy for the Future
All partners in healthcare should take their responsibility in developing the profession of home care nurse The care process should be aimed at the independence of the elderly and their needs, so they can stay at home as long as possible. The relationship between elderly and home care team must be based on trust In Indonesia it is recommended that also informal care-givers (volunteers/ family/neighbours) are involved. The visiting home care nurse should have a central position in this process and supports the informal care givers. Home care nurse as a spider in the web

19 HomeCare4Indonesia Coordination Education: AIPNI, STIKES, FON-UI
Needs elderly + family Self-managing home care team Social welfare Trust-based relationship Quality of Life Health care Intermediary (feedback) A home care system with trust-based relationships, a good quality of care, will improve the quality of life. Based upon the needs of the elderly and their family, social welfare and health care. Health-care is provided by independent home care teams, that cooperate closely with other organisations in health care and social care Initiators from education in this system are AIPNI, STIKES and FON-UI Other actors in healthcare and social system: PUSAKA, Social worker, Hospital, Posyandu (Lansia), Puskesmas, Fysiotherapist, Dietist, Psychologist, Pharmacy …. Quality of care

20 Why trust-based relationships
Visits at home mostly by the same care-givers Home care team knows all about the personal situation of the elderly client, changes in health, is human-centred instead of task-centred Elderly who trust the care givers will not be afraid or ashamed to express their problems Well informed care givers are able to give custom-made care and can give appropriate feedback to doctors about the situation Trust can be considered as the first condition to improve the quality of care and quality of life of the elderly client.

21 HOME CARE NURSE ELDERLY
? East and west, different nurses, different levels, specialised nurses and now also home care nurse

22 6. Competencies home care nurse
Careful Consultation and Advice Communication & negotiation Build up a trust-based relationship Openminded and creative Critical ethical reflection Sense of humor Coordination and organisation Analitical and solution focused Human-centred This is a palette of competencies, linked to each other, important in all education & training of home care nurses. You can consider this as some kind of compass to improve your service during your whole professional life. Developing competencies of home-care nurses needed for client-centred care, Communication skills and negotiation skills: dialoguing is important: Nurses demonstrating ‘dialoguing’ are aware of competing responsibilities and take responsibility together with the client. Client-centred care means commitment with the Client demand, knowing what they want, concerns a process of actively signalling, discussing and negotiating with the client, and actively searching for compromises, or creative solutions, sometimes at organizational level (avocate for patients). Nurses reported having to be very patient sometimes. Dialoguing includes giving and grounding a professional opinion, even if the client did not agree, and respecting the client’s point of view. Professional and personal boundaries are made clear. Respect and partnership, careful consultation and advice: support client participation (negotiate, coach, trust based, humor). It helps when they trust you, clients will not be ashamed to tell you their anxieties, and you will be able to help them better Handle situations of tensions and dilemmas,( solution focused, openness, creativity). Critical ethical reflection means that sometimes wondering if what you do or did is the most effective, or are there better or new ways? Can you improve yourself? Ethical issues in health care particularly affect the elderly for several reasons: older people are sick more often than younger people, suffer more from being in the end stage of various chronic progressive degenerative diseases and are most likely to lack the capacity to make critical decisions when such decisions have to be made. Clients with the capacity to make health care decisions should have the right to make decisions about their own bodies, based upon good access to information. Analytical: sometimes there are underlying causes for a problem. Not problem solving, but solution focused which is a different approach (knowledge & insight, human centred, creative) Human-centred, not task centred. Sometimes some understanding and compassion is valued more than washing and grooming. You can do both at the same time. Be pro-active, if you see that a patient is sitting all day, and barely walks, may be pressure wounds will be the result. Do something about it before that happens. decisionmaking Compassionate Knowledge and insight Dedicated Pro-active Coaching and training Co-operative Respect & partnership

23 To be ahead of new developments
7. Commitment educators To be ahead of new developments and to be pro-active in developing home care Anticipate new developments, don’t wait till a gap arises

24 8. Recommendations to implement home care
Develop a home care curriculum for qualified self-steering home care nurses of different levels. Develop specialised modules elderly home care for existing S1 and D3 nurses (terminal care, incontinence, diabetes etc) Let nurse students work as trainee in the community; Give special attention in home care curriculum to self-steering concepts, dialoguing, coaching and training of informal care givers (e.g. family, neighbours, volunteers) Do applied research to needs elderly Develop new research methods that take into account the specific situation of the elderly people. Start pilots based on feasibility studies Anticipate new developments, don’t wait till a gap arises 24

25 9. Pilot project home care Bali (1)
Goal Sustainable home care system, in the community, by the community and for the community Objectives To increase availability and quality of home care services with self-managing home care teams based upon model HomeCare4Indonesia To stimulate community awareness To develop home care curricula and learning materials

26 Pilot project home care Bali (2)
Project organisation Initiative and coordination: STIKES-Bali Inventarisation of existing projects and organisations involved Selection of community for pilot (desa Pererenan, this village is selected because it has many elderly people and family that moved to the city) Field assessment (needs elderly, what kind of services) Self-managing home care team and coach Cooperation of home care team with other care providers (GP, hospital, health centers Puskesmas and Posyandu) and volunteer organisations (PKK, YKI) Think-tank: criteria, evaluation, research & development home care with representatives from education, hospital doctors/GP’s, nurses and elderly clients Yayasan Kanker Indonesia PKK welfare organisation

27 Pilot project home care Bali (3)
Education & training Short training courses for nurses and volunteers Development information and training materials (self-care guidelines) Budget Budget 1st year STIKES-Bali; after 1st year local government Sponsors: medical devices, smart ICT Evaluation after 1 year

28 10. Preconditions Pro-active Not bureaucratic
Not expensive (low overhead) Nearby Needs-focused Education and training suited to needs elderly clients

29 Thank you for your attention
2025: Home alone or… YOU ARE READY!!! Home alone movy: you should not leave your children alone at home, because terrible things happen, the same goes for the elderly, if we leave them alone, the most terrible things will happen. Thank you for your attention


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