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 A Quick Guide to Starting Private Practice:
- 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 experience. 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!
My experience with home visits for psychotherapy is that the client’s overall needs are often complex requiring case management, and sometimes there are issues of safety, confidentiality, and questionable appropriateness for psychotherapy.
Medicare pays for home visits for psychotherapy if the client is considered “homebound” (see definition below) and these are the folks I’ve visited in private practice. You can imagine that if this is the case the needs are likely complex. They might have a need for case management to help with caregiving, transportation, housing, access to care, and other basic needs. If the issues are complex, dealing with them can interfere with psychotherapy.
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 on the phone before the first visit?
- Region and clientele served
- Safety
- Informed consents 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 requiring a statement from the client’s medical provider regarding their homebound status. If ever you were to be audited by Medicare, this could be a crucial component.
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?
Think About This Home Visit Scenario
You receive a referral from Adult Protective Services or another agency for an elderly client on oxygen who smokes, meets the definition of homebound according to Medicare, and is on high doses of opiates for chronic pain and COPD.
Believe it or not, this is a fairly common situation. The case continues:
The client’s family member lives with her who is apparently a caregiver of sorts but the boundaries are unclear and the client complains about him. He moves out and now the client lives alone, again. She is a high fall risk and still drives locally though she’s been told not to by her doctor. When you express concern regarding safety issues related to living alone (fall risk and medical issues) and attempt to address caregiver problem-solving, she reassures you she is safe by pulling out her loaded handgun that is in a drawer at her bedside. It is the same gun she accidentally shot herself with in a few years prior; she shows you her scar in the same motion as showing you the gun. She prides herself on feeling safe because of the gun. She also insists that lying propped up in her bed is the most comfortable place for her because of her pain. She has a significant history of trauma and is grieving the death of her spouse.
What are your policies and procedures for dealing with this client?
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.
This is an excerpt from a chapter in A Quick Guide to Starting 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.
For more info about the Private Practice Coaching Services I offer, you can check out my website www.privatepracticenavigator.coach. Navigator News is part of the website and my endeavor to make official that which I have been doing unofficially for a while now – helping others navigate the startup of their private psychotherapy practices. If you like what you see please consider sharing with your colleagues and on your social media platforms. Thank you!
McKeegan Insights, LLC / Bonnie McKeegan, LCSW Consulting 