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In-Home Therapy and Home Visits:

When psychotherapists, counselors, social workers and other mental health professionals conduct therapy and assessment in the clients' homes

Outline & Overview

By Ofer Zur, Ph.D.

In-Home Therapy and Home Visits: Home-Based Mental Health

See our online course for CE credits, Out-Of-Office Experiences

 

 

1. PopulationsIn-Home Therapy and Home Visits: Home-Based Mental Health

  • Mental Health
    • Depression
    • Agoraphobia
    • Social Anxiety
    • Contamination phobia
    • Paranoia
    • Developmental disabilities
    • Hoarding
    • Drug abuse
    • Suicidality
  • Evaluation amp; Education
    • Child abuse/neglect/safety
    • Pre amp; post adoption issues
    • Placement
    • Drug abuse
    • Nutrition and cooking education
    • Parenting education
  • Physical-Medical Conditions
    • Autism
    • Home-bound elderly
    • Paraplegics
    • Patients with AIDS/HIV amp; other infectious diseases
    • STD Evaluation
    • Terminally ill amp; 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

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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
  • In-Home Therapy and Home Visits: Home-Based Mental Health

    • 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

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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 issuesIn-Home Therapy and Home Visits: Home-Based Mental Health
    • 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

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 In-Home Therapy and Home Visits: Home-Based Mental Health

 
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)

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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/sIn-Home Therapy and Home Visits: Home-Based Mental Health
    • 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'

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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

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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
    In-Home Therapy and Home Visits: Home-Based Mental Health
  • 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: For sample teaching by Dr. Zur
    • , click here.

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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
  • CPT Codes
    • There are numerous Current Procedural Terminology (CPT) codes that address different types of out-of-office experiences. 
    • Mental health home visits are covered under codes, such as Psychiatric Diagnostic or Evaluative Interview (90801, 90806). 
    • For other CPT codes, click here.

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9.Cost

  • In-Home is Generally Cheaper Than Traditional Medical Office or Hospital-based Therapy
  • In-Home Therapy and Home Visits: Home-Based Mental Health
    • 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

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