MANAJEMEN DEPRESI DI PUSKESMAS KERJASAMA INTERPROFESI DI KABUPATEN SLEMAN DIY (KONDISI AKTUAL DAN REKOMENDASI)

BAMBANG HASTHA YOGA L.B.,DR.,SP.KJ., Prof. dr. Laksono Trisnantoro, M.Sc, Ph.D.; Prof. Dr. Dra. Sofia Retnowati, MS

2015 | Disertasi | S3 Ilmu Kedokteran

Latar belakang Depresi merupakan masalah kesehatan dengan beban biaya yang besar, akibat penurunan produktivitas maupun besarnya biaya penanganan. Depresi merupakan salah satu gangguan jiwa yang seharusnya bisa ditemukan dan ditangani di tingkat layanan primer. Namun selama ini deteksi kasus gangguan depresi di layanan primer masih sangat rendah. Kebijakan JKN menyatakan bahwa puskesmas sebagai layanan primer merupakan saring pertama dalam mendeteksi masalah kesehatan, termasuk gangguan jiwa. Tenaga kesehatan di puskesmas (dokter, perawat, dan psikolog) secara kompetensi sudah memadai untuk melakukan penanganan kasus-kasus depresi. Untuk itu diperlukan panduan penanganan depresi di puskesmas yang memungkinkan kolaborasi di antara para tenaga kesehatan di puskesmas. Tujuan Mengevaluasi pelaksanaan manajemen pasien depresi, mengembangkan model manajemen depresi berdasarkan clinical depression pathway internasional dan standar nasional serta pembiayaannya, mengembangkan sistem pembayaran dan remunerasi untuk psikolog, menguji penerapan clinical pathway penanganan depresi dan memberikan rekomendasi clinical pathway manajemen depresi interprofesi di puskesmas Kabupaten Sleman Daerah Istimewa Metodologi Subyek penelitian adalah dokter umum, perawat, dan psikolog di puskesmas yang memberikan informed consent.Penelitian ini dibagi menjadi 4 tahapan. Tahap I, survey ke puskesmas di Sleman dengan panduan wawancaraterstruktur berdasarkan guideline NICE. Tahap II, mengadakan FGD 1 untuk memaparkan hasil penelitian tahap pertama kepada subyek dan diminta memberikan rekomendasi terhadap clinical pathway untuk depresi yang dikembangkan berdasarkan hasil penelitian tahap pertama serta melakukan FGD 2yang membahas kembali clinical pathway yang telah direvisi sesuai rekomendasi pada FGD 1.Tahap ketiga, review ahli dengan 3 orang pakar dari Australia. Tahap IV, uji feasibilitas clinical pathway di puskesmas. Analisa statistik dilakukan untuk menilai validitas dan reliabilitas instrument yang digunakan pada tahap I dengan uji korelasi Pearson product moment dan analisa Chronbach alpha. Uji t-test tidak berpasangan dilakukan untuk menilai hubungan antara pengetahuan dengan lama lulus dan lama bekerja. Uji one way ANOVA dilakukan untuk menilai perbedaan di antara 3 kelompok profesi. Nilai signifikansi ditetapkan pada p < 0,05. Hasil Subyek penelitian ini adalah 63 orang tenaga kesehatan di puskesmas di Sleman yang terdiri dari dokter umum, perawat, dan psikolog. Tidak didapatkan perbedaan bermakna skor kemampuan skrining antara dokter, perawat, dan psikolog. Terdapat perbedaan bermakna dalam skor kemampuan assessment dimana psikolog mempunyai skor paling tinggi. Hal yang sama juga ditemukan untuk kemampuan edukasi. Terdapat perbedaan bermakna mengenai penanganan depresi ringan dimana psikolog mempunyai skor paling tinggi. Namun untuk terapi sedang dan berat dokter mempunyai skor yang lebih tinggi. Kemampuan rujukan dokter juga lebih tinggi dibanding perawat dan psikolog. Lama kerja berbanding lurus dengan kemampuan assessment, manajemen depresi pada dokter dan psikolog. Kami berhasil mengembangkan clinical pathway depresi dengan penekanan pada kolaborasi interprofesi yang bisa diterapkan di puskesmas di Sleman. Sistem pembayaran tenaga psikolog menggunakan sistem kapitasi JKN. Dana kapitasi digunakan untuk membiayai gaji tenaga BLUD non PNS termasuk dokter, perawat dan psikolog dan pembayaran jasa pelayanan kesehatan. Kesimpulan Peneliti menemukan distribusi kemampuan yang berbeda-beda antara tenaga kesehatan di Puskesmas. Untuk mengoptimalkan kemampuan masingmasing, maka peneliti mengembangkan clinical pathway dengan penekanan pada kolaborasi interprofesi. Tak hanya dokter dan perawat yang mempunyai peranan pada penanganan depresi di Puskesmas, namun juga psikolog. Psikolog mempunyai peran penting dan perlu dikembangkan didaerah lainnya.

Background Depression is a health problem with extensive cost burden, due to decreased productivity and the cost of handling. Depression is a mental disorder that should be found and handled in the primary care level. However, during this time, detection of depressive disorder cases in primary care is still very low. JKN as a government policy states that primary health care as first screening in detecting health problems, including mental disorders. Health providers in primary health care (doctors, nurses, and psychologists) have competencies to handle depression cases. It is necessary to make a treatment guideline of depression in primary health care to enable collaboration among health care provider in primary health care. Objectives Evaluating the implementation of depression cases management, developing a management model based on clinical depression pathway from international and national standards. We also study about financing, payment systems and remuneration for health care provider, including psychologist. Test the application of the clinical pathway treatment of depression and provides recommendations for interprofessional management of depression clinical pathways in primary health care in Sleman Regency. Methods The subjects are general practitioners, nurses, and psychologists at primary health care. This study is divided into 4 stages. Phase I, we conduct a survey to health care provider in Sleman primary health care with a structured interview based on the NICE guideline. Phase II, we conduct focus group discussion 1 to take the results of the first phase of the study, asked them to give recommendations on depression clinical pathways. Then we discuss the recommendation in FGD phase 2. The third phase, the depression clinical pathway is reviewed by 3 experts from Australia. Phase 4, we conduct a feasibility test for depression clinical pathways at the primary health care. Statistical analysis was performed to assess the validity and reliability of the instrument used in the first phase using the Pearson correlation test and Chronbach alpha analysis. Unpaired t-test was performed to assess the relationship between knowledge of health care provider and works duration. One way ANOVA test was performed to assess differences among the 3 groups of professions. The value of significance was set at p <0.05. Results The subjects of this study were 63 health workers in health centers in Sleman consisting of physicians, nurses, and psychologists.There were no significant differences in scores between the screening ability of doctors, nurses, and psychologists. There are significant differences in scores capability assessment in which psychologists have the highest scores. The same was found for the ability of education. There are significant differences regarding the treatment of mild depression where psychologists have the highest scores. However, for the treatment of moderate and severe doctors have higher scores. Physician referral capability is also higher than nurses and psychologists. Duration of work is related with the assessment ability, management of depression in physicians and psychologists. We managed to develop clinical pathways depression with an emphasis on collaboration interprofessional that can be applied in health centers in Sleman. Psychologists is paid by capitation system. JKN funds used to provide non-civil servant salaries including physicians, nurses and psychologists and payment of health care services. Conclusion Researchers found the distribution of different abilities among health care provider in primary health care. To optimize the ability of each provider, the researchers developed clinical pathways with emphasis on interprofessional collaboration. Not only doctors and nurses who have a role in the treatment of depression in the primary Health care, but also a psychologist. Psychologists have an important role and need to develop other areas in Indonesia.

Kata Kunci : depression, clinical pathway, inter-professional, public health centre