Welcome to Bonnie’s Navigator News blog!
From time to time, I’ll post information relevant to private psychotherapy practice. When I learn new stuff related to private practice, I like to share it with colleagues! I hope this proves helpful to you. I promise not to spam your inbox. Rest assured, I don’t have time for that ;-).
In this post you will find an excerpt from the Home Visiting chapter in The 14 Concrete (but not so hard!) Steps to Private Practice (some information in the book has been edited since the writing of this post):
- Pros and cons of home visiting
- Considering your previous home-visiting experience
- Things to think about: environment, safety, complexity, time management, confidentiality, client ability to meaningfully participate in psychotherapy
- Definition of “homebound”
- Medicare and home visits
- Policies and Procedures to consider
- Case scenario
Consider the Pros and Cons of Home Visits
Home visits in the role of a case manager, such as with an agency like hospice, home health, or a chronic care coordination program are great experiences. If you’ve had this opportunity, think about those visits for a moment.
- What type of clients did you visit?
- What were their needs?
- What type of environments did your clients live in?
When you are visiting for the purposes of psychotherapy you’ll need to consider several issues. There are pros for sure:
- Observing and interacting with a client in their home environment can provide oodles of valuable clinical information.
- Home visits can provide services to a population that otherwise may not have the opportunity for psychotherapy services.
- When you have limited office sublet time, you can do home visits to keep money flowing while you build up your in-office clientele.
- When the word gets out that you do home visits, you might fill your practice sooner than you expect!
More Things to Think About in Terms of Home Visits
- Assess your tolerance for environments: If you have a health condition with certain triggers, like animal dander, cigarette or marijuana odor, dust, mold, animal urine or feces, litter box odors, etc then you will need to be more selective about home visits. If you have back problems, trouble with stairs, or a need for a controlled environment in some way, then home visits may not work well for you.
- Time Management: If you decide to do home visits then you’ll need to plan for extra assessment time over the phone, then again during your first visit, before the person becomes your client. Plan for the possibility that you may spend more time in consultation with other providers involved in the case or searching for additional resources than with the average client. Think about the perimeter of your service area. Determine time and distance factors from your office and home. Obviously, home visits require more time, gas, and mileage on your vehicle.
- Assessing for safety: Suicidality, dogs, guns, and other home environmental issues.
- Assessing for confidentiality: Who is likely to be in the home during your visits? Spouse/family/caregivers? Is the person living in an Assisted Living or Independent Senior Living complex? Confidentiality is bound to be blown eventually as other residents and staff notice your presence. Are you required to sign in to the facility?
- Assessing for the appropriateness of psychotherapy. Can the person participate meaningfully? Are the needs more of a case management situation? Who was the referral from and what is the referral source hoping for from your involvement? If the case management type needs are met would they then be appropriate for psychotherapy?
Offering home visits can be a real boost to your practice because so few therapists offer them. Medicare pays the same amount for a home visit to a “homebound” client as it does for an office visit (in my experience).
Policies & Procedures to Consider for Home Visits
Should you decide to offer home visits, you will need to develop additional policies and procedures for
- Assessment – how much will you conduct on the phone before the first visit? Keep reporting requirements and informed consent about your reporting responsibilities in mind.
- Region and clientele served
- Safety
- Informed consent specific to the issues of safety, confidentiality, and the therapist’s determination of the appropriateness of home visits for psychotherapy
- Smoking
- Releases of information
- Maintaining confidentiality
- Determining homebound status
- Where in the home psychotherapy will take place
Regarding Releases of Information: You should consider a policy that requests the client sign Release(s) of Information to the referral source, primary physician, primary caregiver, and other involved agencies or the facility where they live, when appropriate.
Being part of a multidisciplinary team is a helpful approach with complex cases. If the client refuses for certain people, a thorough understanding of why is important. Of course, you would not be planning to discuss certain things with a primary caregiver, but you may need to discuss scheduling or other issues related to caregiving during your presence.
Regarding homebound status: You should also consider a policy that includes consultation with their medical provider regarding their homebound status (if homebound).
Regarding smoking: Will you sit with a client on their porch while they smoke? Are you willing to visit a house where people smoke inside?
Regarding where in the home psychotherapy will take place: Consider your policy regarding the location in the house where therapy will occur. Many clients who are homebound are not physically bedbound, but they’ve “taken themselves to bed” and conduct nearly all of their life stuff from bed. Are you willing to conduct therapy at the bedside?
Medicare’s Definition of “Homebound”
Medicare considers you homebound if:
- You need the help of another person or medical equipment such as crutches, a walker, or a wheelchair to leave your home, or your doctor believes that your health or illness could get worse if you leave your home
- And, it is difficult for you to leave your home and you typically cannot do so.
Your doctor should decide if you are homebound based on their evaluation of your condition. If you qualify for Medicare’s home health benefit, your plan of care will also certify that you are homebound.
From: https://www.medicareinteractive.org/get-answers/medicare-covered-services/home-health-services/the-homebound-requirement
This is an excerpt (book chapter has been updated) from a chapter in The 14 Concrete (but not so hard!) Steps to Private Practice If you are still considering offering home visits for psychotherapy, there are more things to know such as rules around Place of Service on claims, hospice status, skilled nursing facilities, and Medicare Advantage Plans.
Image by DarkWorkX from Pixabay
The 14 Concrete Steps to Private Practice 