In-Home Therapy and Home Visits

1. Populations

• Mental Health
  • Depression
  • Agoraphobia
  • Social Anxiety
  • Contamination phobia
  • Paranoia
  • Developmental disabilities
  • Hoarding
  • Drug abuse
  • Suicidality
• Evaluation & Education
  • Child abuse/neglect/safety
  • Pre & post adoption issues
  • Placement
  • Drug abuse
  • Nutrition and cooking education
  • Parenting education
• Physical-Medical Conditions
  • Autism
  • Home-bound elderly
  • Paraplegics
  • Patients with AIDS/HIV & other infectious diseases
  • STD Evaluation
  • Terminally ill & dying clients, hospice
  • Dementia, Alzheimer’s
  • Other disabilities or home-bound people
• Culture/Setting
  • Some cultures (i.e., American Indians) seem to prefer home visits
  • Cultures with negative stigma regarding mental health treatment
  • Many minority clients do not trust medical services from outside their communities
• Other Limitations
  • Disorganization
  • Lack of funds
  • No access to transportation
  • Cannot leave children or home bound family members at home

Top of Page
 

 
2. Advantages

• • Comfort
    • Patients are seen on their turf – in their real lives
    • Opportunity to observe the conditions patients live in
  • Assessing & Intervening in Context

• • Can treat or intervene in patient’s environment, not just with pills or from afar
  • Highly effective for: Parenting issues interventions; Child abuse/danger eval; and Pre & post adoption issues
  • Understanding the patient’s environment
  • As they say: “Health isn’t just a diagnosis, it is how you live”
• Cutting ER and Hospitalization Costs
  • ER visits and hospitalizations are very expensive in comparison to home visits
  • Home visits can prevent ER visits and hospitalization by dealing with the problems before crisis occurs
  • There is a surge in in-home or home-based therapy in the 21st century due to increased demand from aging population, advance radiology and lab technologies, and pressure to decrease the cost of mental health and medical treatments
  • Home-based therapy works well in conjunction with tele-medicine, tele-health, and tele-mental-health to provide effective and low cost treatment

Top of Page
 

 
3. Boundaries

• General
  • Home visits present a more complex set of boundaries
  • Unlike the clinical office, with its clock, furniture, soundproofing & waiting room, home visits provide a more fluid and unpredictable setting
  • Home visits require more flexibility from therapists
  • It is a unique setting with unique boundaries issues
• Space
  • Where treatment takes place: Living room, bedroom, porch, backyard, bathroom, car, nearby park, library, school, church, or trail.
  • Important to consider what is around the treatment area
  • Physical space – What is conducive, what is prohibitive for productive work? For healthy relationships?
  • Can interview the client in their living room, during a walk in the neighborhood, or on a car ride
• Role
  • Role confusion or Role Slippage in home based therapy
  • Therapist may be viewed not only as a social worker or therapist, but also as a guest or friend
  • Guest vs. therapist is tricky: Guest needs to be attended to and served vs. therapist’s role to attend to client
  • Therapists should avoid being perceived as rude if they refuse a snack or drink
  • If one eats with the family or is served coffee or tea, it may look more social than professional
  • More informal conversation (small talk) in home-based therapy in comparison with office-based therapy is normal
  • Therapists may also act as driver, house cleaner, decorator, babysitter, etc. They may help with shopping for modeling or pragmatic purposes
  • Therapists may also help clean the house for hygiene, safety, or modeling purposes
  • Extreme example: Therapist may kill a possibly rabid skunk that threatens a family
  • Therapist may need to help a disabled or elderly client get dressed or go to the bathroom
• Time
  • How long are the sessions?
  • Ending on time or leaving on time can be tricky
  • Starting when the family is ready
  • Getting to home late due to traffic issues
  • Getting to home early before child goes to school or parents to work
  • Avoiding later in the day visit due to violence in neighborhood or increased chance of drunkenness or drug abuse in PM
  • Protocol: Inform clients of how long do you expect to be there
  • Give clients a range of time of arrival
• Who is Present
  • Family members of patient
  • Abusive boyfriend
  • Controlling husband/wife/son
  • Visiting neighbors
  • Neighbors who are curious
  • Unwelcomed intruder
  • It is impossible to predict or to always control who may be present
• Self Disclosure
  • Being asked personal questions in the informal home setting is more common than in traditional medical settings
  • Refusing/accepting certain foods or drinks can be revealing
  • It is often appropriate to dress more casually
  • Therapist’s car or other mode of transport can be of interest to the client and can reveal personal information, such as if there is a baby seat in the car or the car is very new and expensive or very old and inexpensive
  • Therapists’ intentional or unintentional, planned or unplanned, conscious or unconscious responses to certain occurrences (that would not come up in a more controlled environment) are telling
• Food
  • How to respond to clients inviting therapists for a family meal?
  • How to respond to clients offering drinks?
  • With some cultures (Chinese, Middle-Eastern, Latino, African American) refusing to join a meal is insulting
  • Is eating part of therapy? Gives impression of friend
  • Food shopping, preparation, cooking, storage and proper meals can be part of the treatment plan
• Alcohol
  • How to respond when alcohol is being offered or served during meal or at cocktail time
  • How to respond when clients and other people in the home are drinking alcohol during the home visit
• Gifts
  • How to respond to gifts offered
  • Appropriate (children’s drawings) and inappropriate gifts (expensive or otherwise inappropriate)
  • Refusing a gift can be insulting, diminish trust, and damage the therapeutic alliance
  • Differential between ethical vs. un-ethical and appropriate and inappropriate gifts
• Interference
  • Children wandering into room
  • Family members interfering
  • Uninvited neighbors, friends, strangers
  • Dogs barking, snarling or attaching
  • Radio, TV, Computers, Cell phones
• Driving a Client
  • Driving a child to school, foster home or another temporary home
  • Driving client to emergency room or medical appointment
  • Driving patient to grocery store, pharmacy or bus stop
  • Sometimes the car is the only place where a social worker or therapist can talk to client privately
  • Some clients prefer the privacy and the ‘side-by-side’ setup of cars
• More Opportunities to Challenge Boundaries
  • Clients may act differently on their home turf than in a medical office
  • Clients may be under the influence of drugs or alcohol
  • Clients have more knowledge of the rules of their homes and neighborhood than the therapist
  • Clients have more control over the environment
  • Clients may have more latitude in the home setting than in a traditional office with:
    • Clothing
    • Alcohol & drugs
    • Use of cell phone, TV, and computer
    • Food
    • Language
    • Moving in and out of ‘session’
    • Pets
  • Clients may ask therapist for:
    • A ride
    • Send a letter
    • Write a letter
    • Make a call
    • Advocate
    • Give someone else a ride
    • Money
    • Babysit while client runs an errand
  • Clients can display extreme behavior on their home turf
    • Open the door naked to greet therapist
    • Therapist can be threatened physically by a client or someone else
    • Clients may drink and/or serve alcohol or use drugs openly
    • Clients may let scary dogs bark or snarl at the therapist
    • Clients may try to match the therapist up with a client’s family member
    • Clients may try to sexually seduce the therapist
  • Clients may display at the home:
    • Legal weapons
    • Illegal weapons
    • Illegal drugs
    • Fighting animals
• Power
  • Power relationships may vary according to the home setup, clients, Neighborhood, therapists, etc.
  • Host (client) may be associated with power
  • Clients have more knowledge, freedom, mobility than the therapist in the home setting
  • Clients can play the power card at home by:
    • Controlling TV, computers
    • Locking doors
    • Allowing children to disrupt or attack the therapist
    • Ignoring the therapist
    • Taking a phone call
    • Making the therapist wait
    • Failing to orient the therapist
    • Trying to make the therapist feel uncomfortable or unwelcome

Top of Page
 

 
4. Confidentiality

• Non-Clients
  • Non-patient family members may be present or within earshot
  • Neighbors may be in the vicinity
  • When social workers need to interview the whole family together and individually in the course of one visit, complex issues arise
• Sound Issues
  • Normal rooms at home are not as private as professional offices
  • Meeting with clients may also be in a public place
• General
  • Confidentiality can easily be compromised in home-based therapy
  • Therapists may choose to go for a walk or in car to achieve privacy (thinking creatively)

Top of Page
 

 
5. Security

• Home
  • Security-safety issues with: Patient/s, family members, neighbors, vicious dogs, or dogs bred for dog-fighting or other pets
• Neighborhood
  • High crime areas
  • Housing projects
• Vulnerability
  • Women are vulnerable in general to physically dangerous situations
  • Women may be more vulnerable in situations of domestic violence where a man abuses his female partner
  • Men who treat women and are treated suspiciously by men
  • Men who try to interfere in domestic violence may get hurt (like policemen)
• Special Situations
  • Fear that that the therapist will take away the client’s children may result in violent or erratic behavior
  • The therapist or social worker may need to take child away
  • Domestic violence (dangerous for police, and others)
• Time
  • Early in the day is generally safer than late in the day
  • Avoid late evening visits
• Presence of Weapon/s
  • How to respond when weapons (legal or illegal) are visible or displayed at the home?
• Presence of Threat/s
  • Threat in the neighborhood
  • Dangerously dirty or un-sanitized conditions
  • Current or former abusive husband, wife, boyfriend
  • Vicious dog
  • Bug, lice, bed-bug infestation
• Safety Measures
  • Google clients before first home visit
  • Review criminal records, when available
  • Know the neighborhood
  • Know your way in and out
  • Screen for weapons, vicious dogs & other safety issues
  • Come with a team rather than alone
  • Come with police presence if necessary
  • Wear flat shoes so you are mobile
  • If necessary, park your car nearby & point it in the direction of an escape route rather than toward a dead end cul-de-sac
• Skills
  • Quick assessment skills and well-tuned instincts are essential
  • Relevant training is extremely important
  • Experience is invaluable
  • Learning from ‘mistakes’

Top of Page
 

 
6. Orientations

• Family Systems
  • Very appropriate for in-home therapy
• Social Work
  • Child safety evaluations
  • Pre/post adoption issues
  • Foster care evaluations and follow up
• Cultural Sensibility
  • For some cultures, home visits are necessary and it has special meaning
• CBT
  • Appropriate for in-home therapy
• Hospice
  • Clearly, home-based therapy is often the only choice
• Medical
  • Hospice
  • Nutrition
  • Medication management & education
  • Physical rehabilitation centers
  • Prevention & avoiding ER visits and hospitalization
  • Test: X-Ray, Labs, STD eval, etc.
  • Rehab at home

Top of Page
 

 
7. Training & Supervision

• • Uniqueness of Home-Based Therapy
    • This unique modality requires special training and ongoing support
    • The ambiguity and uncertainty of the work requires ongoing supervision and debriefing as necessary
    • Some people are not suited to this job, and they should be screened out as early as possible
    • Supervision, peer support and debriefing can reduce burnout
  • Therapists Must Learn To
    • Be more flexible
    • Increase capacity to be light on their feet and respond appropriately to new, unusual and surprising situations, demands and occurrences
    • Present calm, secured and self-assured
    • Protect against burnout
  • Screening
    • Important to thoroughly screen potential candidates for home-based therapy
    • Obviously, conducting in-home or home-based therapy is NOT for everyone
    • Requires assessment of whether an intern or new employee is a good fit for this unique and challenging type of a job
    • Screening should focus on workers capacity to think on their feet, deal with complex interactions, manage crises effectively with flexibility, assertiveness, etc.
  • Training
    • Very important for in-home or home-visit psychotherapy
    • Must prepare new comers for the complexities
    • New workers shadowing experienced ones is an excellent way to introduce the line of work and train new therapists
    • Senior and new therapists going together as a team is one of the more effective way to train new workers
    • Lack of training can put the worker or therapist in harms way

• Modalities
  • Individual supervision
  • Group supervision
  • Peer supervision
  • Peer support
• Technologies
  • Role play
  • Videos
  • Modeling onsite (senior and junior going together)
  • Teaching & discussions
• Debriefing
  • Important in burnout prevention
  • Can reduce stress and absenteeism
  • Important after extreme or traumatic situations, preferable done on an ongoing (weekly) basis
  • Can be part of peer supervision or peer support group
• Burnout Prevention
  • Supervision
  • Debriefing
  • Peer consultation
  • Stress reduction
  • Education, workshops, presentations: Sample teaching by Dr. Zur

Top of Page
 

 
8.Records & Billing

• Records Must Contain
  • Signed consents and authorizations
  • Time of arrival and departure
  • Who was there or who was not there
  • Clinical notes on session
  • Unusual occurrences
  • Boundary considerations
  • Clinical rational for interventions
• Informed Consents
  • Patients sign informed consent (limits of confidentiality, reporting laws, etc)
  • Verbal clarification of the nature, intent, scope, etc. of the home visit
• Billing & CPT Codes
  • There are several billable CPT codes that address home visits.
  • Mental health home visits are covered under codes, such as Psychiatric Diagnostic or Evaluative Interview.
  • CPT codes

Top of Page
 

 
9.Cost

• • In-Home is Generally Cheaper Than Traditional Medical Office or Hospital-based Therapy

• • Averting ER visits
  • Avoiding Hospitalization
  • Averting Psychiatric Hospitalization
  • Less ‘support staff’
  • No medical building rent/mortgage
  • Minimal overhead
  • Use of advance radiology and lab technologies
  • Use in combination with tele-medicine
  • Some estimates: 5% of the cost of ‘standard’ medicine
• In-Home Can be More Expensive Than Traditional Medical Office or Hospital-based Therapy
  • Visits are typically longer than office
  • Driving time
  • Driving cost
  • Can fit fewer clients in working day
  • Reimbursement rates by Medicare are lower for home visits in comparison to office visits

Top of Page