Implementation of Home Care Services by Community Health Centers (Puskesmas) in Makassar City, Indonesia

Home care services by health professionals, such as doctors, nurses, and other health care professionals, target to provide health care services, including health education, physical examination, or other treatments such as physical therapy or medication. This study aimed to evaluate the implementation of home care (nursing care and home care services) in Makassar City in accordance with government guidelines. A qualitative descriptive study was conducted by interviewing nurses (15 participants) from several community health centers (Puskesmas) in Makassar City, Indonesia who have implemented a home care program for at least a year. Four main themes had emerged, namely, management of home care services, nurses’ roles in home care services, perceived barriers, and community benefits. Despite some barriers, the home care programs delivered by health care professionals including nurses in Puskesmas in Makassar City have been well implemented in accordance with the guidelines. On the basis of the obstacles faced by the nurses, one recommendation is for the government to provide specific guidelines on the types of patients to be included in these services. The government also needs to ensure that the community knows the types of patients’ condition who can avail these services.


Introduction
Life expectancy has risen substantially, and socio-demographic changes in the last decades have affected home care needs (Genet et al., 2012;World Health Organization, 2021). Most health care systems in many countries underwent significant transformation (Braun & Cony-beare, 2017;Genet et al., 2012). Home care has been implemented worldwide as a comprehensive system of community health care services (Braun & Conybeare, 2017;Genet et al., 2012;Shahsavari et al., 2018) where health professionals provide a form of care at patients' homes. In an ideal situation, community health care should be a multidisciplinary team effort in which nurses play an important role alongside general practitioners, psychologists, physiotherapists, nutritionists, midwives, and other specialists (Feltner et al., 2014).
Home care services in most countries included hospital-based home nursing services, customized visiting health services, and long-term care insurance-based nursing services (Zeng et al., 2015). Home care is an ongoing program that focuses on long-term care to improve patient care, minimize treatment costs, and reduce hospitalization period and queuing at the hospital (Wojtak & Stark, 2016).
In many countries, home care services are a WHO recommendation. Home care services in the form of home visits by health professionals, such as doctors, nurses, and pharmacists, aim to provide health care services, including health education, physical examination, or other treatments such as physical therapy or medication (Zeng et al., 2015). In Australia, for example, home care is one of the fastest-growing health program and is supported by the Australian Federal Government, which also establishes home care specifically for the elderly above 65 years old or for indigenous Australians aged 50 years or above with chronic illness and disability (Palesy et al., 2018). However, the implementation of home care services is challenging and effortful due to the variety of services delivered and the lack of human resource (Shahsavari et al., 2018). As a developing country in Southeast Asia, Indonesia also has implemented home care services as one of the solutions to anticipate the number of patients who cannot be accommodated in the hospital but do not need hospital equipment (Putra et al., 2018). In Indonesia, home care service is a part or continuation of sustainable and comprehensive health services provided to individuals and families in their homes and aims to improve, maintain, or restore health or maximize the level of independence and minimize the effect of the disease (Ministry of Health Republic of Indonesia, 2014). In Indonesia, home care services are provided by hospitals, community health centers (Pus-kesmas), and private healthcare providers (not affiliated with hospitals or Puskesmas). However, this program is not provided by all hospitals and Puskesmas in Indonesia and is mostly conducted only in large cities and province's capital. Various level of health care services are delivered to the community in accordance with the government policy in each province (Ministry of Health Republic of Indonesia, 2019). In Makassar City, home care services are mostly provided by Puskesmas. Only one hospital provides home care services, in which the program is optional but not covered by Indonesian health insurance (BPJS). The hospital mainly focused on follow-up home care services, and the patients should pay for these services.
In Indonesia, the population has rapidly grown with around 262 million people in 2017, and the morbidity rate has also increased due to tropical and degenerative diseases (Ministry of Health Republic of Indonesia, 2018). This situation is a challenge for the government towards public services in Indonesia. To date, communities complained of government programs because they neither meet the interests of the community nor provide essential benefits in terms of health, especially for the poor or lower middle class (Putra et al., 2018).
South Sulawesi, one of the provinces in Indonesia, has realized the innovation of health care and has developed home care services since 2015 (Jaringan Inovasi Pelayanan Publik Sulsel, 2019). This innovation is important especially in Makassar City because of its uneven public health services that require improvement by improving facilities and infrastructure and increasing community access to health services (Putra et al., 2018). As stated in the Makassar City government regulation, Puskesmas is the coordinator of home care service and is responsible for its management in Makassar City (Health Office South Sulawesi, 2017; Jaringan Inovasi Pelayanan Publik Sulsel, 2019). Home care services are provided by a team consisting of doctors, nurses, other health workers, and a case coordinator that is usually a nurse from Pus-kesmas (Putra et al., 2018;Suprapto, 2018).
Home care in Makassar has been well implemented since 2015 by 46 health centers throughout the city (Putra et al., 2018) as evidenced by the number of home care service innovation users in 2016 (around 3,379 patients) (Jaringan Inovasi Pelayanan Publik Sulsel, 2019). The implementation of home care is inseparable from the help and support of the local government in the form of a mini ambulance, namely, Dottoro'ta (Our Doctor), ECG equipment, and Telemedicine (Putra et al., 2018). However, home care is not necessarily implemented as per the definition set by the Makassar City government. The annually growing number of home care users confirmed that this program has spread widely and is growing rapidly in Makassar City. However, the number of users does not guarantee that the quality and accuracy of the services provided follow the concept of home care and the role of health workers in providing services. A previous study described the home care program in Makassar City but did not explore the specific roles of nurses and the implementation of this program (Suprapto, 2018). Thus, evaluating the implementation of home care services provided by Puskesmas in Makassar City from the nurses' perspectives is important.

Methods
Design and participants. A qualitative, exploratory, and descriptive study was conducted by selecting 15 nurses involved in home care service using purposive sampling and subjecting them to semi-structured interviews (McKenna & Copnell, 2020). The research team consisted of nursing lecturers who have experiences in qualitative nursing research and nursing students (all females) who have conducted interviews in the community. Prior to the interview, the nursing students were trained by the team leader (Doctoral in Community Health Nursing) on how to conduct interview and underwent an interview practice (pilot test of two participants who were previously involved in the program but were moved to another service and were not included in the data collection analysis) prior to do the interview. This study was conducted from September to October 2019 in several Puskesmas in Makassar City that implement home care service. A letter was sent to the Makassar City Health Office to ask permission and determine which Puskesmas implement home care service. From 23 Puskesmas in Makassar City, only 15 implement home care programs. Letters were then sent to the heads of the 15 Puskesmas to ask the list of nurses who provide home care service and can participate in this study. A meeting was arranged to conduct interview with the participants.
Interview process and data analysis. All the nurses from 15 Puskesmas agreed to join the study, and the face-to-face interview was conducted for around 40-60 minutes by the researcher mostly in the Puskesmas where the nurses work. No relationship existed between the research team and the participants prior to the study, and their formed relations were merely limited to the research context. This interview was conducted in Bahasa Indonesia and recorded with permission from the participants. Field notes were also taken during the interview. Data were transcribed to verbatim in Bahasa Indonesia after each interview and analyzed using Open Code 4.03 software (ICT Services and System Development and Division of Epidemiology and Global Health, 2015) to obtain an overview of the experience conducting home care for later comparison with literature (Holloway, 2017). The data were treated with qualitative narrative using thematic analysis derived from data coding (McKenna & Copnell, 2020;Speziale, 2011).

Rigor.
The transcribed text of the interviews was read and reread to capture the experience of the nurses participating in this study. Process data were simultaneously collected and analyzed (Holloway, 2017). To ensure rigor, Creswell and Poth (2018) suggested that the researcher should at least use two methods for trustworthiness in a qualitative study. Rigor in the present study was obtained by researcher triangulation and member checking methods (Miles et al., 2014). In researcher triangulation, different investigators compare the collected data or the conclusions reached by different analysts looking at the same body of data (Miles et al., 2014). In the current study, three research team members independently analyzed the data and then compared the results together to draw conclusions. The researchers then sent the brief summary of the finding to the participants for member checking. Six participants were randomly selected to check for accuracy and resonance with their experiences (Birt et al., 2016).
Ethical consideration. Ethics approval was obtained from the Faculty of Medicine Ethics Committee Universitas Hasanuddin (Ethic no: 895/UH4.6.4.5.31/PP36/2019). The participants also received an explanation of the research and provided informed consent prior to the interview. Codes were used in reporting data to ensure that no participant can be identified and maintain the confidentiality of their names (Holloway, 2017).

Results
Face-to-face interview was conducted with 15 nurses (13 females and 2 males) who provide home care services. All the participants were aged between 33 and 50 years and have been working for over 5 years in the Puskesmas. Table 1 shows the participants' characteristics. After analysis, the data were grouped into four themes each consisting of some sub-themes ( Table 2).

Management of home care services.
In this study, we aim to evaluate whether home care service were implemented in accordance with the guidelines issued by the Makassar City government. The Makassar City government has decided that all home care services provided are free to the community who live in the Puskesmas working area. These services are based on patients' call to the call center and are divided into three categories of services, including emergency home care service, home care visits for patients who are sick but cannot go to Puskesmas for treatment, and home care follow-up vi-sit for patients who need follow-up care after being hospitalized. The healthcare teams generally consist of one doctor, one nurse, and one other healthcare staff. The government has regulated that the rewards for the team should come from the Makassar City revenue and expenditure budget. Data analysis showed that home care management was implemented in accordance with the government regulation. This first theme included three sub-themes, namely, providing service based on patients' call, government policy of the type services, and specific reward for the home care team members. The participants described that home care will be delivered on the basis of the patient's call. A patient who needs home care services could call the service center (112) as indicated in the home care guidelines from the Makassar City government. The participants are aware of the flow and mechanism of the services as mentioned by one of them: "…. mechanism of services is the patient should call center 112, then the call center will forward it (the information) to the team of home care and report that there are patients who need service, after that, we will visit the patient's home." (P2) Data analysis showed that the type of services offered were in line with the government policy. All the participants said that based on the government policy, the three types of services offered were emergency, home visit, and follow-up visit. Nevertheless, no limitation was set on home care services, and all types of diseases were handled. In this regard, a nurse who has worked for over 13 years stated that, "Now the concept of home care in Makassar city is a home visit, emergency care, and follow-up, almost all cases are served in this home care program, and it is the government's policy to treat all diseases…" (P1) The reward for home care staff has already been set as per the government regulation. This issue is important and directly influences home care Barriers perceived. In this study, we asked about the obstacles faced by nurses in implementing home care services. Data analysis showed that some of the barriers to home care implementation based on nurses' experiences included long-hour services, lack of health staff in Puskesmas, and community misperception of the provided services. One of the barriers to home care implementation was that the staff should be ready to provide 24-hour services.
"… so many obstacles, we need to go to patients' homes, and usually  In this study, an important barrier of home care was community misperception of home care services. The community appears to take advantage of this program because the Mayor of Makassar City emphasized that all patients' call should be answered and visited. However, the guideline has regulated that only certain cases can be visited. Among emergency cases, home visit is only for certain patients with chronic diseases and those who physically cannot go to healthcare facilities because of physical barriers. However, the guideline does not have a clear With these obstacles, the nurses hoped for improvement in the socialization system of the home care services for the community. All the participants believed that the community must be given adequate information so they can have an accurate understanding and interpretation of the services, especially the criteria to qualify for home care services.
Benefits for community. Regardless of the barriers, the nurses believed that this program is good and helps people in the community to get healthcare services, especially those with specific conditions that impede them from visiting Puskesmas or hospitals. The nurses described their hopefulness related home care, "I think this is an excellent program to increase community health status." (P3) Other participants shared a story from one of the patients who really appreciated the home care services, especially those who have physical restrictions preventing them to go outside their homes. In addition, this home care service program is equipped with a car that has telehealth facility and important equipment required for the services. One participant mentioned, "Regardless the current system in these ser-vices, I think this program has helped community to get health care services faster. If we want to send the patient to the hospital, we can send the data first by telehealth facilities in Dottorotta' car" (P4)

Discussion
This study showed that the home care program provides services according to the patient call. Its flow and mechanism have been described in the home care program guidelines from the Makassar City government (Dinas Kesehatan Kota Makassar, 2015). The participants are aware of the flow and mechanism of the services. According to the guidelines, the patient first needs to contact the call center, which will then screen and forward the call to the appointed Puskesmas of the local health center or the Makassar City home call center (Jaringan Inovasi Pelayanan Publik Sulsel, 2019). This study described the type of home care services stated in the government policy, including home care services for patients who cannot go to Puskesmas or hospitals (home care visit services), patients with emergency condition (emergency home care), and patients who need follow-up care posthospitalization such as wound care and physiotherapy for stroke patients (home care followup). Given that the home care program explored in this study is one of the innovation programs of the Makassar City Mayor in 2015, its regulation somewhat differed from the home care services in other regions of Indonesia and other countries, although the guidelines were developed based on the Indonesian government regulation (Ministry of Health Republic of Indonesia, 2014). The Indonesian Hospitals Association has formulated the concepts and mechanisms of home care services, including the collaboration between hospital and Puskesmas regarding patient selection (Widyastoeti, 2020). The doctor in the hospital will decide whether the patient needs home care service and will contact the home health care agency to perform follow-up care. This agency can be Puskesmas or any other private healthcare providers offering home health care services. This phenome-non is one of the limitations of home care services in Indonesia. Owing to the lack of regulation, the implementation of the program can vary among the regions in Indonesia. For example, in one region in Yogyakarta, home care services are provided specifically for elderly in collaboration with healthcare providers and the community (Sumini et al., 2020). In developed countries, such as Australia, home care services focus on supportive care for patients after discharge from the hospital to maintain the health of disabled people and the elderly at home, prevent unnecessary admission, and meet the daily needs of these patients (Palesy et al., 2018). The varying implementations and focuses of home care services in different countries depend on their policy objective for home care (Palesy et al., 2018).
This study revealed that nurses have the main role in the team, and this result is supported by WHO study stating that nurses are the key member of the home care team (Genet et al., 2012). In addition, nurses perform their nursing role including assessment, implementation of nursing care according to patient problems, and documentation of nursing care using resume reports. The nurses involved in home care services team reported that their main task is to provide nursing care. They also have other tasks such as educating the patients and their family. Tóthová et al. (2014) explained that nurses use a holistic approach in providing nursing care including preventive care, health education, and health management. Nurses also provide the coordination and continuity of health care for individuals, families, and communities. However, in the current study, the nurses reported that their task is simple and short and not specific for nursing care.
Several barriers in the implementation of home care services were also perceived by the nurses. In this study, providing 24-hour services was one of the obstacles faced by the nurses. Another barrier was the lack of home care staff. Similar findings were obtained by another study, which explained an occasional delay in ho-me care services due to this issue (Haswira et al., 2019). The lack of human resources in Puskesmas has become an issue, resulting in one nurse doing more than one task (Kadar et al., 2014). One study about innovation in health care argued that human resources are the most important element in implementing home care innovation policies (Putra et al., 2018). Another barrier faced in implementing home care was misinterpretation from the community about the service, particularly the patients' conditions included in the home care service program. One recent study confirmed this finding and recommended that the government must limit home care services to certain type of diseases to maximize the health care services provided (Haswira et al., 2019). Shahsavari et al. (2018) explained that society's understanding and interpretation of home nursing care could affect the utilization modes of home care. The present study also found that reward system was an important issue for the nurses. Given that the reward issue was not included in the barriers faced by the nurses, its impact on the nurses' work was not further explored. This condition can affect the performance of nurses: two studies explained that financial rewards have a positive impact on employees' performance (Putra et al., 2018;Shahsavari et al., 2018).
Despite the barriers perceived by the nurses, the participants agreed that this program gives benefits for the community, especially for individuals who have physical restraints to go to the hospital or Puskesmas to receive health care services. One of the goals of this home care service program is to make health care services accessible for all communities in Makassar City. Regardless the benefits, the participants hoped for the improved management of the home care program, including the development of administrative protocols and coverage of home care services. Good management is one of the key components in implementing effective public health program (Frieden, 2014), such as home care services. In addition, these home care services must be introduced to the community to gain their understanding and perception. Clear, accurate, and timely communication among the health care community, decision-makers, and the public can prevent misunderstandings about the program (Frieden, 2014). One limitation is that this study did not include the experiences of the other members of the home care team. To maintain the generalization of the results, this study took the total sample of nurses as a team of home care at several public health centers in this city.

Conclusion
Four main themes emerged in this study, namely, management of home care services, roles of nurses in the home care service, perceived barriers, and community benefits. On the basis of nurses' experiences, the home care program delivered by health care professionals including the nurses at Puskesmas has been appropriately implemented in accordance with the guidelines. However, some barriers were perceived by the nurses. In relation to the benefits received by the community from this program, the government should provide additional technical guidelines, especially regarding the types of patients' condition that could receive these services.