Standardized Operational Procedures of Home Care Services

During the implementation of any program in an international standardized hospital, a standardized operational procedure is necessary. Although it has already been established in outpatient and inpatient services, there is no standardized operational procedure in home care service of Home Care Unit in SH. It is necessary to establish a standardized operational procedure for home care service. Thus, operating the home care service according to the standardized operational procedure is legally and practically safe.

“So, there is SOP (standardized operational procedure) in standardization, there is an existing policy. In standardization, there should be control, monitoring, and evaluation. So, it means that the standardization that can always be revised in accordance with the evaluation results and evolving needs. Then, what is more important is how to set-up patient facility at home. How to make compatible environment for safe service delivery. For example bathroom design, bedroom design, closet design in patients who need home care is precisely the highest patient safety factor, which is now still not much appreciated, so there should be one agency or another team that assess the readiness of the design, a particular design of the spoon must also be considered.” (P1)

“I only followed JCI. But, actually, JCI is designed for outpatient and inpatient care, there is no home care. So, I keep making, but by my own opinion, I adjust it. Oh, this is the standard in inpatient services. I guess it's the same at home care. Some that are similar, I took it.” (P2)

“Yes, with hospital by law, everything is safe. It means that it is protected by law. So, less emergency case is managed at home care, if it's still, if there is still emergency, then it should be treated at the hospital.” (P3b)

Medical Recording Problems

In the past 7 years, to face the 4.0 industrial revolution era, SH has developed integrated e-medical record managed by medical record installation. It is now making the medical services, both inpatient and outpatient, more effective and efficient. However, Home Care Unit is not yet linked to the integrated e-medical records. This resulted in poor home care service collaboration and difficulty in reviewing the patients' conditions.

“In the future we will, once again, we will further implement the use of E-Medical Records including IT and developing technology related to internet, including data that will later be collected from these services will also be recorded in the big data. … Once again, Sardjito has gradually implemented the E-Medical record.” (P1)

“Medical record … here at half to eight everyone is ready, at quarter to eight we usually already hold the morning meeting, in preparation to go to the field. Well, because it is early morning usually medical records installation will not be willing to serve us that early so we have to deal with that… we manage medical records by ourselves, like that.”(P2)

“The quality of stroke patients management that is carried out post-hospitalization by the home care team does not only depend on clinical problems. But it is also non-clinical or administrative. Thus it needs is a standard medical record integrated with the hospital medical record to confirm the medical record during his hospitalization at Sardjito Hospital. Medical records forms for stroke patients should be created or developed by the hospital home care team, including what contents are necessary, how the follow-up is handled, who performed it.” (P3a)

Home Care Service Quality Control

Home care service quality control in SH is stated in the policy of guideline development in every service activity for patients. It is necessary to refer to the clinical care pathway to control the medical service quality. However, the home care service in SH was lacking of an integrated clinical care pathway.

“To provide the service, we follow clinical pathway, whether it is available or not yet available, it is indeed a homework that has to be done, but there are also SOP. So, it means, the core is the clinical pathway, but later on for procedures there are SOP, it must be created and updated continuously.” (P1)

“Stroke management guidelines conducted by the Sadjito Home Care Team, the management is also general. So, if it is a stroke patient, to be honest, there is no specific guideline yet. The obstacle is that there is no clinical pathway for homecare service here.” (P3b)

“For stroke patients specifically there are No. specific guidelines, we only rely on our competence. If it is necessary, we still consult the attending neurologist. Because the problem of stroke patients themselves is usually not because of the disease, but the result of stroke itself, for example stroke complications.” (P4a)

“Not yet doc. For stroke, not yet.” (P5a)

“For specific … for specific case, not yet.” (P5b)

“Oh, for physiotherapy, we have, doc. But, we don't specifically have for this … very specific we have our own … No.” (P6a)

“Yes, the evaluation is through the medical record form that describes the subjective, objective, assessment and planning. What date did he come, when was he scheduled to come, when was the control and so on. Even if it is necessary, if found other things or complication, it can be referred by neurologist to other relevant specialists.” (P3a)

“In practice … we have the ADL (activity daily living). We evaluate the ADL, yes.” (P3b)

As a result, there was no standardized care during home care visit for postacute-stroke patients. There was no standardized operational procedure among doctors, nurses, or physiotherapists when they perform home care visit. Besides providing continuous care, the main role of home care services is to educate the patients and their families. Every health personnel would perform home care visit according to their own understanding of what the patients may need because there is no standardized operational procedure, integrated clinical care pathway, specific care plan, and integrated medical records. Furthermore, it would be difficult to evaluate the results of the care from the previous home care visit since there is no integrated medical records, specific care plan, or standardized evaluation tools for every patient, since different health care providers visit and perform home care service for the patients in a determined period of time, either daily, weekly, or monthly.

“At first we explain to the patient's family about the dependency of post-acute stroke patient, because the general public's paradigm thinks why the patient was discharged when they had not been able to carry out daily activities. Therefore, explanations must be given related to the dependency of these patients is a residual symptom of the stroke, and this home care service aims to improve the patient's condition. Then we look at the patient's environment, because the patient is a high risk patient, so we must educate the patient's family, and evaluate the diet.” (P4a)

“The first thing we do is a complete examination, including patient awareness, vital signs and we explored all. At the beginning of the examination at home, we usually evaluate the problems that were brought home from the hospital, make sure we have data and remember the patient's problems. After we evaluate and provide treatment for the patient, we also educate the patient's family. Because the progress of the patient also depends on the support of the family itself.” (P4b)

“We often see it from the wound care, with a target of three months for wound improvement, that we already have. Because we mostly do wound care, doc. Wound care and NGT that take a long time. Even though it's slow, it's usually improving.” (P5a)

“For evaluation procedure we also ask for family approval first. For example, the family wants it to be only once per week.” (P5b)

“Yes, depending on the progress. So, no waiting, don't have to wait for me, sometimes the condition is fluctuative. Some are stable, some are unstable.” (P6a)

“For patients, especially physiotherapy evaluation is done every month. Initially we set the goal of ADL improvement for these patients. In practice, it hasn't been achieved, it doesn't matter, but we have ADL or measurable goals. So, it depends on us.” (P6b)

Financial Problems

Indonesian National Healthcare Insurance did not cover the fee for home care service. Therefore, according to the hospital policy, home care services cost should be reasonable compared with the cost of inpatient care.

“Home care service must be cheaper than inpatient services, if indeed it is needed, two things can be done: 1. Sell the premium, service will be covered. 2. We must involve the community. … If the patient doesn't have money, we have to facilitate the patient's family to be independent. Self sufficient is the keyword at the Ministry of Health. So, in principle we cannot force National Health Insurance to cover home care services.” (P1)

Without the coverage of Indonesian National Healthcare Insurance, home care service is certainly unattractive for patients. To date, home care service is an out-of-pocket service directly paid by the patient. It had not been integrated with the hospital's financial system and there is no standardized payment.

“There is no standardisation of the payment procedure for home care personnels who do home visit. So far, it still uses the fees determined by the hospital, but not based on unit costs. So rather not consider if there is any complication, do not consider distances, do not consider how many people are involved in. It should be calculated in unit costs. Now this is a financial obstacle. Well, and even then there are other financial constraints that the type of the payment is from individuals to individuals. Ideally, it is from patients to institutions.” (P3a)

According to the mutual understanding between the health care personnel and patients or patients' caregivers, the payment system is also informed and consented. The home care service manager preferred the payment to be made in advance of the provided service to avoid any misconduct from both parties.

“Well, in the past the payment was paid later after the service had been given. But, I was cheated till I could not collect millions of money. So pity for the healthcare personnels who had already worked hard. Like that. So, now I make a deposit system. Indeed I did not make a package, because every patients needs are different.” (P2)

Lack of Capable Human Resources in Home Care Service Unit

SH already had systems and regulations in terms of human resources development to catch up with the development of the latest medical science and technology. However, weak leadership becomes an obstacle in continuing the medical education for knowledge and skill improvement of every health personnel. On the other hand, there is a need for each health personnel to be able to perform their tasks with the same standards.

“… Informally, I have also stated to the directorate of medical and nursing that each employee must be able to master one new skill each year. If the skills improvement is related to the line of work, we will afford it financially. Our employees are currently have difficulty in learning, in other words, Learning Disability.” (P1)

“Now, we hope for this home care unit personnels, each member has a specialization related to the task specification, to optimize the care for stroke patients in particular.” (P3a)

All general practitioners and nurses who are working in home care services of SH have received training for the management of neurological patients. However, lack of continuing medical education routinely for specific knowledge and skill refreshing made the health care personnel focused only on patient's general care, such as managing the noticeable wound care without performing thorough examinations on possible other complications of poststroke.

“Not too often attending seminar about stroke management, last time it was 1 year ago.” (P4a)

“Wound care course, basic neurology, mostly in the wound care, twice in wound management.” (P5a)

“Maybe just some seminars, the topic … neurology once. But already in the 2014s.” (P5b)

“Uh, the last time if I may say it in order, eh Bobath course. That was introductory, just the beginning. Then followed by integrated and multidisciplinary approach on physiotherapy at, eh, Singapore General Hospital, precisely at the academia during the 2018 stroke congress. In addition, there are several courses related to management on, eh… eh… Rehabilitation and Integrated Cancer Course in Singapore 2017.” (P6a)

Human resources' quality and quantity are necessary to be improved for further development of home care services unit, given the potential public interest in the home care services. This, in turn, will affect the quality of the provided home care services and the performance of the home care services unit in SH.

“Lack of human resources is a burden for home care services, so the primary need is human resources, we have a lot patients to serve and are spread in many areas.” (P4a)

“It is very often that we are getting sick alternately, among us. For example, I have to take a day off since I am too sick to work, usually catching a cold or getting dizzy, my friend would got overloaded with work for several days to also cover my work. And then, in turn, he will need to take a day off after that.” (P5a)

“Do you mean in a week? That depends on the initial management plan. Then, depending also on, what the term is, restrictions are possible. But ideally for the acute phase of stroke that I know of, I would be scheduled for 2-3 visits per week within the first 3 months of stroke phase. But usually we fulfill only 2 times because of limited personnels.” (P6b)

Home Care Services Unit Staffs' Welfare Needs More Attention

Currently, there is no standardized incentive for home care staff. This makes home care service unattractive for staffs to be involved in.

“Yes, so far because it is a social indication. And the variability is high. There are those who just say thank you, only give gifts, and some money only around 200 thousand to 300 thousand Rupiah (13-20 USD) per visit. The highest is only 300 thousand Rupiah (20 USD), without considering the distance. So, that sometimes increases the inconvenience. In the end, we just say 'we only got that much, instead of split it and get too little, let's just buy some food' usually just like that.” (P3b)

General practitioners and nurses as the main personnel who performed the medical tasks in home care services expected more consideration from management regarding safety and incentive according to the level of risks that they faced daily. The nurses said that overall they were satisfied with the current condition, but there were several things that can certainly be improved, especially in terms of benefits and incentives.

“The trip to the patient's house for each visit could take a half to an hour, from one house to another house. Sometimes it's hot or raining, but we keep on going. So, hopefully there will be more appreciation for us as home care doctors. Transportation is also an obstacle. Hopefully, the director can provide a means of transportation for home care services.” (P4b)

“(I am) satisfied. Even though I heard that our takehome pay is less than they are who take shifts in the ward. But, so far, we are quite satisfied, because we understand they also have night shifts, we have different levels of stressors. So with this takehome pay, I am quite satisfied. Yes, at my own risk. The vehicle are still fully on our own.” (P5a)

“The welfare of the staffs … I don't think so … yesterday we have proposed … for example, we ride our own vehicles to reach the patient's house. There is also no consideration of risk and takehome pay. There is transport allowance. But the payment is uncertain, that's why.” (P5b)

“Yes, improvement in everything is needed. In terms of human resources too, then eh, welfare.” (P5b)

Home Care Services in SH: Policy vs Reality

The Government Regulation No. 44/2009, Article 32, stated that every patient has the right to obtain humane, fair, honest, and high-quality health services, without discrimination in accordance with professional standards as well as effective and efficient standardized operational procedures to avoid physical and material losses, and receive information regarding his/her diagnosis, medical procedure, the purpose of medical procedure, alternative procedure, possible risks and complications, prognosis, as well as estimated cost of treatment. In addition, patient has the rights to complain about hospital services that are not in accordance with service standards through print and electronic media in accordance with statutory provisions.10

One of the patient rights that must be fulfilled by the hospital is to get services with standards in accordance with the provisions of the applicable laws and regulations. Despite the policy, not all patients' needs were fulfilled properly because the ratio between patients and medical staff available at the home care services unit is not ideal. Patients' rights are fulfilled by creating mutual understanding and negotiating between management and patients. This includes risk assessment, patient identification and risk management, incident reporting and analysis, the ability to learn and follow-up on incidents, and implementing solutions to reduce and minimize risk occurrence. Integrating human rights training for health care providers at all levels is essential.12 To maintain patient safety, it is recommended that negligence errors should be a safety priority, including focus on preventive health care interventions and implementing of the following five steps that can improve patient safety by changing physician behavior. According to Cook et al (2004),17 the five steps are: (1) environmental scanning, (2) understanding current behavior, (3) target behavior for change (why, what, when, where, and who), (4) adopting effective strategies for changing behavior, and (5) synergize.

Regulation of the Minister of Health of Republic of Indonesia No 1438/MENKES/PER/IX /2010 Regarding Medical Service Standards, Article 3, stated: (1) Medical service standards include National Medical Service Guidelines (NMSG) and standardized operational procedure (SOP); (2) NMSG as referred in Clause 1 is a national Medical Service Standard and is made by professional organizations and approved by the Minister; and (3) SOP as referred in Clause 1 is made and determined by the head of the health service facility. Article 10 stated: (1) The head of the health service facility shall initiate SOP development according to the type and level of the health service facility he leads; (2) NMSG must be used as a reference in the development of SOP in the health service facility; (3) SOP must be used as a guide for all health workers in health care facilities in providing health services; (4) SOP is prepared in the form of Clinical Practice Guidelines that can be supplemented with clinical pathways, algorithms, protocols, procedure, or standing order; and (5) Clinical Practice Guidelines as referred to in Clause 4 must contain at least the definition, history taking, physical examination, diagnostic criteria, differential diagnosis, supporting examinations, therapy, education, prognosis, and literature.18

Despite the policy, care pathway and standardized operational procedures in Home Care Unit of SH are not yet established. To commence the quality improvement process, it is necessary to apply the following steps: (1) problem identification, (2) analysis of the causes of the problem, (3) solution development, (4) implementation, evaluation, and solution refinement, and (5) permanently implementing the health system and improving the solution.19

Another infrastructure problem of home care services in SH is the disintegrated medical records from the hospital's e-medical records. Medical records are compilations of scientific data from various sources, coordinated into documents and available for various personal and impersonal uses. According to Government Regulation of Republic of Indonesia No. 44/2009, SH is required to organize medical records, as a form of reflection of accountable health services.10 Conventional medical records are writings/notes/documentation that chronologically and systematically describe and explain the medical history of a person's diseases. Difficulties in filling medical record in home care services always become a burden, for instance when home care nurses must maintain interaction with the patients, including eye contact and other services, making it difficult for nurses to fill out medical records while providing home care services. A strategy to overcome this is to remember what needs to be documented and write it later.20 21

Electronic health record (EHR) can also be implemented in home care service. A study reported that with the implementation of EHR, there was a high level of satisfaction from clinicians especially in the sub-items of completeness and data accuracy. In addition, the highest impact was found on the timeliness of filling the EHR and the ease of insurance claims.22 The focus of patient care process optimization is the utilization of Internet-based and interconnected information technology systems to attain efficient and effective services.23

According to SH's policy, home care services cost must be more efficient than inpatient care with mutual cooperation principle. Until now, the income of the home care services unit has been directly paid by patients and has not been integrated with the hospital's financial system. Home care services are not covered by Indonesian National Healthcare Insurance and only covered by private insurances. This needs to be reconsidered. In European countries, home care services are provided by the government and continue to grow realizing the importance of home care services, although some countries such as Germany, Netherlands, and Spain still have not implemented home care services into centralized health financing.11

The average total cost for home care services is lower than outpatient services in hospitals. Standard rate calculation should consider complication, risk factor, and worsening of clinical condition. Patients who received home care services had higher average increase in the Barthel Index than who received outpatients' care. From qualitative perspective, patients and their families were quite satisfied with home care services and prefer home care services rather than outpatient services in hospitals.24

Improvement in Human Resources' Capabilities and Welfare is Necessary

According to Setyawati (2004),25 home care team includes the following staffs: (1) health professionals group, including nurses or professional nurses, doctors, physiotherapists, occupational therapists, speech therapists, nutritionists, radiologists, medical laboratory technologists, and psychologists; (2) nonhealth professional groups, including social employees and spiritual leaders or religious experts; and (3) nonprofessional groups, including nurse assistants who serve as assistants waiting to serve the needs or daily activities of the client (caregiver). This group works under the supervision and direction of the nurse. However, it is not easy to maintain many parties involved in home care services due to diverse clinical and organizational decisions, and the difficulty of uniting medical personnel.26

The constraints regarding the human resources in home care services were insufficient number of staff and lack of human resources recruitment strategies. This can be seen from four aspects: (1) compensation, that is, staff felt not getting enough compensation and compensation also varied across countries, (2) education and training, (3) quality assurance, and (4) working environment conditions. Considering these four aspects, the strategy that can be employed in recruitment should include giving trial periods for applicants and offering training programs. In addition, in terms of compensation given there are also recommendations for attracting applicants, along with other benefits.27 28

Staff welfare has been regulated in a performance-based take-home pay system. However, staff still felt the amount is unattractive because it does not consider the risks of providing services outside the hospital. Service quality is directly affected by employee benefit policies and sustainability. Incentive is a good way to motivate performance and loyalty of employees, especially employees from service sector.29

The reward system expresses and reinforces the values and norms that shape company culture. A careful consideration of reward system design can help decision-makers succeed by modifying organizational culture. Reward system is basically a powerful mechanism that can be used by managers to communicate desired attitudes and behaviors to members of the organization. It is believed that over time, culture can accept change through clear communication of performance, as well as consistent criteria and application of rewards.30