TABLE OF CONTENTS 1. Populations 2. Advantages 3. Boundaries 4. Confidentiality 5. Security 6. Orientations 7. Training & Supervision 8. Records & Billing 9. Cost

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 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 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 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) 5. Security & Safety 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' 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 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: For sample teaching by Dr. Zur, click here. 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. 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

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