INTERVENSI DALAM

KOMUNITAS
COMMUNITY HEALTH NURSING
TUJUAN PEMBELAJARAN
Mendiskusikan konsep intervensi dalam keperawatan komunitas

Mendiskusikan konsep rujukan dalam asuhan keperawatan komunitas

Mendiskusikan konsep pengembangan kebijakan dalam asuhan keperawatan

komunitas

Mendiskusikan konsep komunikasi media massa dalam asuhan keperawatan

komunitas

Mendiskusikan konsep advokasi dalam asuhan keperawatan komunitas

Mendiskusikan konsep case management dalam askep komunitas

 Consultant

Case
Researcher
manager

Clinician

collaborator Educator

Advocate Counselor

MAJOR ROLE FUNCTION OF CHN

“Caring” In The Community Level
Keperawatan komunitas berada pada tataran praktek yang
berbeda dengan spesialisasi keperawatan lainnya, focus pada
kelompok resiko dan rentan masalah kesehatan begitu juga
seluruh komponen masyarakat, tidak terbatas pada ruang dan
waktu.

Public health nursing recognized the link between politics,

economic, social needs and the health status of the public
_Lilian Wald_
Program Planning
o Perencanaan adalah salah satu kunci keberhasilan
program yang akan dilaksanakan setelah proses
pengkajian selesai
Step 4

Mapping
Step 3

Choosing
Step 2

Analyzing
Step 1

Defining
Langkah-Langkah Perencanaan
o Identifikasi
prioritas dari diagnosa yang telah
dimunculkan
o Merancang tujuan umum dan khusus
o Merancang aktivitas/program untuk mencapai tujuan
o Merancang rencana implementasi
o Merancang budgeting
o Menyusun program keseluruhan
 Tahapan Proses Perencanaan Intervensi
Membentuk Tim perencana

Menentukan tujuan umum dan khusus

Melibatkan
sasaran intervensi Identifikasi Sumber daya dan tantangan
Sesuai dengan
Dibentuk dari masalah yang Menentukan metode
berbagai bidang diangkat Sumber daya dan kegiatan
keahlian Tujuan berkaitan erat berupa dana, situasi
dengan jenis komunitas, layanan Disesuaikan
program yang akan yang ada dengan kondisi
dilakukan Kendala yang komunitas (nilai,
memungkinkan culture,
dihadapi pendidikan dsb)
Sesuaikan dengan
tujuan yang ingin
dicapau
Strategi Intervensi
Komunitas
5 Strategi yang umum dilakukan :
1. Pendidikan Kesehatan
2. Pembentukan grup
3. Pemberdayaan Masyarakat
4. Partnership
5. Pemberian layanan
keperawatan
Chronic Illness
o 2005 data showed that more than 133 million people, or almost half of all
Americans, live with a chronic condition.
o That number is projected to increase by more than one percent per year
by 2030, resulting in an estimated population of 171 million requiring
chronic disease management
o Almost half of all people with chronic illness have multiple conditions.
o As a result, many managed care and integrated delivery systems have
taken a great interest in correcting the many deficiencies in current
management of diseases such as diabetes, heart disease, depression,
asthma and others
o Problem in health care system :
o Lack of care coordination
o Lack of active follow up to ensure the best outcomes
o Patients inadequate training to manage their illness
 Chronic Care Model System
• Improve patients outcome
• Make care delivery more efficient
• Improve access and timeliness of medical care
• Boost the usability of health care system
• Lower cost
• Reduce medical errors and inappropriate care
 Referral System
(Community Health
Practice)
 SISTEM RUJUKAN
Sistem Rujukan pelayanan kesehatan adalah penyelenggaraan pelayanan
kesehatan yang mengatur pelimpahan tugas dan tanggung jawab
pelayanan kesehatan secara timbal balik baik vertikal maupun horizontal

A referral can be defined as a process in which a health worker at a one

level of the health system, having insufficient resources (drugs,
equipment, skills) to manage a clinical condition, seeks the assistance of a
better or differently resourced facility at the same or higher level to assist
in, or take over the management of, the client’s case
A good referral system can help to ensure
o Clients
receive optimal care at the appropriate level and
not unnecessarily costly
o Hospital facilities are used optimally and cost-effectively
o Clients
who most need specialist services can accessing
them in a timely way
o Primary health services are well utilized and their
reputation is enhanced
The design and functioning of a referral system in
any individual country will be influenced by:

HEALTH SYSTEMS
DETERMINANTS
• capabilities of lower levels;
availability of specialized
personnel; training capacity;
organizational
arrangements; cultural
issues, political issues, and
traditions
GENERAL DETERMINANTS
• population size and density;
terrain and distances
between urban centres;
pattern and burden of
disease; demand for and
ability to pay for referral
care
Case study : Establishing Referral Networks for Comprehensive HIV Care in
Low-Resource Settings
To help PLHA (persons living with
HIV/AIDS) obtain the highest
level of qol

To help caregivers and • To meeting the

family with HIV/AIDS needs of PLHA
• To maintaining or
ESTABLISHING re-establishing
To facilitate their active REFERRAL
participation in contact with
decisions making
NETWORK clients and
families who need
ongoing care and
To promote social support
acceptance and respect
Proposed Models of Referral Networks
1. Health facility-based referral networks
2. Community-based referral networks
3. HIV case management referral network model
 Health facility-based referral network

Health facility (referring

organization)
----------------------------------------
 Diagnoses client. Receiving organization
 Provides ongoing treatment. ----------------------------
 Coordinates the network.  Receives client.
 Refers client for services not  Provides service.
provided on site.  Documents service.
 Follows up with client and  Refers clients to other
receiving organization. needed services
 Documents referral activity.
 Conducts quality assurance
 Community-based referral network
Health facility or VCT site
· Diagnoses client.
· Provides treatment.
· Refers to CBO (Com Based Org)

Receiving organization
· Receives client.
Community-based organization · Provides service.
· Receives client referred from facility or VCT site. · Documents service.
· Provides services and/or refers client for · Refers clients to other
services. needed services
· Follows up with client.
· Documents referral activity.
· Coordinates network.
· Conducts quality assurance
HIV case management model of referral
network
o In which patients are assigned to a case manager, a professional who helps patients
and families define and meet their needs
o An HIV case manager performs the following general functions :
 Identify and conduct outreach to clients.
 Assess the comprehensive needs of the client and caregivers.
 Develop an individual service plan with the client and caregivers.
 Implement the service plan by linking with the service delivery system.
 Monitor service delivery.
 Advocate for clients.
 Continue evaluation of client needs.
HIV case management model of referral network
Health facility or VCT site
· Diagnoses client.
· Provides treatment.
· Refers to case manager

Community-based organization or health facility Receiving organization

· Receives client.
Case manager · Provides service.
· Establishes partnership with client that can be long- · Documents service.
term, based on client’s needs.
· Refers clients to other
· Identifies client needs.
· Refers client for treatment and services. needed services.
· Follows up with client.
· Documents referral activity.
· Advocates for client to meet needs across the
continuum of care.
· Conducts quality assurance.
 Case Management

The Case Management Society of America defines case

management as:
"a collaborative process of assessment, planning, facilitation
and advocacy for options and services to meet an individual's
health needs through communication and available resources
to promote quality cost-effective outcomes."
 Case Management goals:
 Enhance health status and
functionality of clients;
 Maximize client access to
services;
 Use resources cost-effectively;  to reduce expensive hospital utilisation
(principally in terms of emergency
 Integrate & coordinate services admissions but also in terms of length of
provided by multiple disciplines stay)
Cohen (1996)  to improve care outcomes for patients
 to enhance the patient experience.

Ross, Curry, Goodwin (2011)

Five Principles of
Nursing Case Management

 Focuses on clients and families with complex issues

 Involves negotiation, coordinating, and procuring services
and resources
 Entails using a clinical reasoning process
 Network development of multi-disciplinary relationships
 Is episode- or continuum-focused
Cohen, E (1996)
Nurse case management in the Community
Setting
 Health promotion & disease prevention
 Prevent escalation of client condition
 Comprehensive & collaborative care
 Efficient use of health care services
 Practice guidelines, clinical pathways & client/family
outcomes improve effectivity
The Case Management Process
 Case finding & risk appraisal
 Nursing interventions matched against characteristics &
needs of the risk group
 Co-ordination of services & continuum of care
 Evaluation of individual & group outcomes

Bower, K. (1992) & Mullahy, C.M. (1995)

Relationship to other Intervention
o In
often generates referrals to others, but it can also be
the result of a referral
o Outreach
and case-finding often precedes case
management
o Implementing case management frequently relies on
health teaching, counseling, consultation, advocacy, and
collaboration
o Case management often leads to advocacy and
collaboration at community
The Roles and Qualities Required of a Case
Manager
o adequate training and clinical experience
o pedagogical skills in order to educate the patient and
his family and to provide them with the information that
they need to understand both the disease and its
treatment.
o communication, negotiation and conflict resolution
skills
oa capacity for self-affirmation
o strong problem-solving abilities
Cont,…
o aptitude
for teamwork and a propensity for hosting
meetings
o Significant leadership and decision-making qualities
o show investigative skills in order to oversee, evaluate
and correct the implementation of the clinical pathway
plans
o be able to write clearly and effectively
CASE STUDY : Program Develops Nurse Case
Managers For Chronically Ill Children
o Itwas implemented to reduce the fragmentation of
services for children and families needing long-terms
interventions
o The goal of the program are to :
o Promote integration of services
o Reduce unnecessary health care expenditures
o Promote the integrity of the family unit and the family’s ability to
access health services
o Empower family members to better manage their children’s care
 Intervention
o Home Health Nursing
o Community Empowerment : SHG
o Collaboration : school
o Partnership : referral system
o Health education
o Children
o Family
o School staff member
o Community member
 The Community Health Nurse acts as advocate for the
Individual , group, or community client

ADVOCATE

Advocacy is the act of speaking or acting for an individual

or group of individuals who may be unable to speak for
themselves.
 HEALTH PROMOTION PROGRAM

advocacy
Community :
Know, felt need,
community
Empower participation
Partnership
ment to develop
healthy
behaviour
Social
support
Simple Complex
action actions
It demands that the
nurse be
Involves action of knowledgeable about
loving and caring for health care system, the
others law and unique Concepts of
characteristics of the advocacy
client

To ensure that the

Help the client system does not
prevent access to
develop full necessary services to
potential which the client is
entitled
 Goals of Advocacy

CLIENT SYSTEM
INDEPENDENCE IMPROVEMENT
Encourages client Improve the
to be an active system to make it
participant in more sensitive and
individual health relevant to the
care needs of the client

Uses tools of public

health policy
Self care (health
development and
care performed by
advocacy for
the client)
needed policy
changes
Basic steps for advocacy
o Assess the nature and source of the issue to be addressed
o Determine appropriate “target” for the advocacy intervention
o Establish the objectives with the client
o Negotiate the action plan with the client
o Determine resources availability
o Assess to what extent the advocacy “target” may be
receptive, and adjust the action plan accordingly
o Implement

o Evaluate
ADVOCACY, POLICY
MAKING AND SOCIAL
MARKETING
 Pemantauan/monitoring
<

o Kumpulan data/info/kebijakan Lobi

Negoisasi
o Analisis kebijakan/data/info Mediasi
Dialog
Petisi-Resolosi

Pengaruhi
Pembuat opini &
Persiapan & Media massa
Bentuk
Pelaksanaan Jejaring inti
Pilih isu strategis Perubahan

>
Kemas semenarik Kebijakan publik
Kesehatan
mungkin Pengaruhi pem-
masyarakat
buat & pelaksana
kebijakan
Identifikasi
Mobilisasi
Pemercaya/mitra Seminar
Perencanaan strategi Kampanye
Siaran/penggunaan Media
Jajak pendapat
Debat
Selebaran
Klp. peduli

> >
Evaluasi/penilaian
 Policy making : modifying current patterns
of action

Homes
(computer, Policy Bodies
TV) (congress,
Individual executive branch)
directed, Specific
Individu Organization
information-
mediated
-directed Organization
Organization (health
change
setting departments,
(Counseling, companies etc)
teachers etc)

Focus Intervention strategy Focus

 Politics and Policy
(Mason, Talbott & Leavitt, 1993)
Politics

Competing sets of values Policy makers

Scarcity of
Resources Competing sets of interests Influencing Actors
Multiple interest groups

Value choices
Decision making

Policy
Kesehatan Masyarakat & Kebijakan publik
Kesehatan masyarakat adalah tanggung jawab dari
pemegang kebijakan
o Sedangkan kebijakan kesehatan merupakan aturan yang
bertujuan untuk meningkatkan dan melindungi
kesehatan masyarakat, mencegah sakit, dan
memastikan kesehatan dapat dicapai oleh semua
anggota masyarakat.
 UNDANG UNDANG NO 36 TAHUN 2009
TENTANG KESEHATAN
( UU NO 36 TAHUN 2009 )

Pasal 5: Setiap orang mempunyai hak yang sama dalam

memperoleh akses atas sumber daya di bidang
kesehatan dan berhak atas pelayanan kesehatan yang
aman, bermutu, terjangkau

Pasal 14: Pemerintah bertanggung jawab merencanakan,

mengatur, menyelenggarakan, membina, dan mengawasi
penyelenggaraan upaya kesehatan yang merata dan terjangkau
oleh masyarakat
►Kebijakan kesehatan dapat
dilihat sebagai jaringan
keputusan (decision-
networking) yang saling
berhubungan untuk
membentuk suatu strategi
atau pendekatan dalam
berhubungan dengan isu-
isu praktis mengenai
pelayanan kesehatan
 POLICY – MAKING PROCESS
POLICIES
Governments ENVIRONMENTS POPULATION and
Funding, Services, PATTERNS
and other (home, work, INDIVIDUAL
and Information Of personal and
organizations school, and health and
ORGANIZATIONS community living
provide community) welfare
RESOURCES

Creating
Re-distributed by shape affecting potential for
 POLICY SHAPE AND
SETTING
Executive Legislative

• Kenali area yang

akan dimasuki
untuk membuat
kebijakan Community Public Policy Political
• Pada isu-isu khusus perspectives Power, Policy, processes
yang hanya and Politics Power
mencakup sasaran
tertentu, maka pilih
area terkecil atau
local untuk
membangun
pengaruh yang lebih
kuat
Community
Commitment
Health
For the Action
Problem
 POLICY GOALS, TOOL Executive Legislative
AND RESOURCES

• Pilih tujuan yang Public Policy Political

adapt terukur kriteria Community
perspectives Power, Policy, processes
keberhasilannya and Politics Power
• Instrument yang
digunakan bisa
berupa pajak, subsidi,
regulasi/aturan, atau
mekanisme pasar
Community
Commitment
Health
For the Action
Problem
 THE PLAYERS AS
STAKEHOLDER
Executive Legislative

• Pilih pemain mana

yang kira-kira memiliki
ketertarikan kuat
terhadap isu atau Public Policy
kebijakan yang ingin Community Political
perspectives Power, Policy, processes
kita perjuangkan
• Ketertarikan mereka and Politics Power
membuat komitmen
untuk berjuang
bersama kita
• Pejabat  kekuasaan
• Pebisnis  keuntungan
Community
Commitment
Health
For the Action
Problem
 PLAYERS
CONNECTION
Executive Legislative

• Bangun aliansi yang

solid dengan model
membangun dukungan Community Public Policy Political
yang berkelanjutan perspectives Power, Policy, processes
and Politics Power

Community
Commitment
Health
For the Action
Problem
Strategi dalam membangun kebijakan
o Pelajari isu-isu strategis yang dapat dikembangkan
o Bargaining

o Manfaatkan media massa sebagai agen propaganda

o Pendidikan kesehatan
 Implementasi Evaluasi

Implementasi
Membuat kebijakan
dan Evaluasi menjadi aturan
Output yang dapat
diukur  sesuai
kebijakan /perundang
undangan
dengan tujuan

Policy impact/dampak
Sosialisasi kebijakan
kebijakan baik
dan pendanaan bagi
langsung maupun
setiap aktivitas produk
tidak langsung,
kebijakan/program
negative atau positif
 Contoh Penerapan Kebijakan Kesehatan
o Kampanye anti
tembakau di
Oregon
o Menaikkan pajak
tembakau
o Mengeluarkan
kebijakan untuk
pangsa pasar
rokok
Strategi untuk membentuk isu-isu strategis : Media
/ Social Marketing
MEDIA

INTEREST GROUPS • NEWS COVERAGE PUBLIC

• EDITORIALS
• OPINION POLL
REPORTS
• LEGISLATIVE • CONSUMERS
• POLITICAL ADS
COMMITTEE • AUDIENCES
• BUREAUCRATIC UNITS • TAXPAYERS
• PARTIES • VOTERS
• LOBBIES OF • POLITICAL
INDUSTRIES, LABOR, CONTRIBUTORS
PROFESSION

Public Policy Making

Social Marketing
o SocialMarketing utilize commercial marketing principles
and technologies for programs designed to influence
knowledge, attitudes, values, beliefs, behaviors, and
practice of population of interest
BASIC STEPS FOR SOCIAL MARKETING
o PLANNING
o Analyze the situation (social environment, potencial target, identify
issue, strategies)
o Set goals and objectives, specify behavior, condition and policies to be
changed
o Determine primary and secondary audiences
o Understand “target audience”
o Develop a plan addressing 4P _Product, price, place and promotion_
o Develop communication strategy
o Conduct message testing
o Refine product and material
o Build in process evaluation measures
Implementation and evaluation
o Implementation
o Produce product and material planned
o Coordinate with partners
o Implement intervention
o Conduct process evaluation
o Refine product, materials and ways presenting them as neeeded

o Evaluation
o Conduct outcome evaluation
o Refine social marketing strategy
Membentuk isu
Kata kunci :
Pendekatan yang bijak
(pas/sesuai, cara yang baik
dan benar, sesuai sikon),

Strategi : Langkah pokok :

Membangun kepercayaan Definisikan isu strategis
Menentukan tujuan advokasi
(Menyamakan persepsi,
Mengembangkan pesan advokasi
menjalin jaringan/ Penggalangan sumberdaya ter-
kemitraan/kerjasama dan masuk dana
mengembangkannya lebih lanjut) Mengembangkan rencana kerja
Membuat pesan yang efektif
oS = Statement/pernyataan
oE = Evidence/fakta
oE = Example/contoh yg menyentuh
o “A” = Advocacy action/tindakan advokasi
43 juta anak Indonesia usia 0 – 14 th tinggal dengan
Perokok.
Merokok menyebabkan kematian karena kanker paru

Biaya penanggulangan penyakit yg disebabkan rokok

memakan biaya 54,1 trilyun rupiah, sedangkan biaya
Depkes hanya 2,913 trilyun rupiah/tahun
Thank you