In the 1930s, approximately 40 percent of all patient encounters happened in the home, according to the American Academy of Family Physicians. By 1950, that number had dropped to 10 percent and 30 years later, the practice was almost non-existent.
Recently, however, house calls have been making a comeback, but with a twist. In some cases, behavioral health specialists are becoming part of an integrated care team that aims to treat the whole patient.
Kirke McVay, MA, private practitioner in Bennington, Vermont, made his first mobile visit several years ago, when one of his patients had spinal surgery and was bedridden.
Because the patient’s home was located near his office, he was able to continue treating her without interruption in that setting. He pointed out that home visits for those unable to drive also allows for continuous behavioral health care.
While the patients he treats in their home might have any number of diagnoses, McVay said that agoraphobia is common.
“I teach them progressive muscle relaxation and the cognitive aspects of the illness,” he said, noting that the ultimate goal is to help the patient move beyond the home environment and into public.
McVay pointed out that in-home visits are sometimes the best option for patients who are on probation or parole, have a curfew or are under house arrest. But before agreeing to see patients outside of the office, McVay suggests therapists “know their clients” and the environment in which they will treat them.
Vermont Psychological Association President Craig Knapp, Ph.D., has had significant experience in treating patients in settings other than his office.
“There are several legitimate reasons for out-of-office visits,” he said.
In addition to seeing patients in the home, mobile psychologists might practice in skilled nursing facilities, schools and/or prisons. He noted that some agencies contract with nursing homes to conduct evaluations and offer treatment for residents; these situations prove to be more viable financially since the clinician might see several patients in that one setting.
Knapp has always made home visits part of his family and forensic evaluations. He explained that when youngsters are involved, home visits minimize the trauma on the child.
“Home is where I first want to see the child,” he said, adding that the home visits can be beneficial for all patient populations. “In the office, you get a snapshot of the patient and a sense of the psychological issues. But human problems are more complex. In my professional opinion, there is real value in seeing a person in his natural context.”
However, in-home visits are not without risk, according to Knapp. “You have to use good solid clinical judgment, be aware of your ethical responsibilities, boundaries and practical circumstances. You have to set limits for yourself and the client. It’s better to set those conditions in advance,” he said. “Every case is different so you have to be flexible. You also have to be self-aware and can’t judge people or their circumstances.”
The Veteran’s Administration has been a leader in delivering home-based care for more than a decade, according to Brian Zuzelo, Psy.D., psychologist at the Edith Nourse Rogers Memorial Veterans Hospital at the Bedford VA in Massachusetts.
The Home Based Primary Care (HBPC) program brings together a team of medical professionals, including psychologists, who provide in-home services for veterans who are unable to travel because of disability, age or health problems, he explained.
“Psychology was integrated into the program to provide mental health care for veterans coping with situational stress, adapting to aging and health problems, chronic mental health problems, cognitive impairment and end-of-life issues,” he said.
In his role with the HBPC program, Zuzelo helps to provide the other team members with insight into the patient regarding health and psychological issues. He pointed out that some veterans might have long-standing mental health issues that intensify when he or she develops a chronic health condition.
By seeing the veteran in the home, the mental health professional can tailor care to the individual. “We have the opportunity to look at the environment and understand how it’s a reflection of internal processes,” Zuzelo said.
For example, in the home, the clinician sees firsthand a client’s artwork collections, hobbies and other items that represent personality, which helps in understanding how a person is adapting to life.
“In the home, you get the rich opportunity to see the person’s strengths and adaptive qualities. You probably wouldn’t have seen this if they came to an office,” he said. “This helps us tailor our decision-making and capitalize on things to improve quality of life.”
From all accounts, patients find favor with the home visits, according to Zuzelo. “Some of the older veterans tell us it reminds them of house calls from long ago,” he said.
The patient demographic is primarily in its 60s, but Zuzelo sees some who are in their 90s. For some of these veterans, loneliness can be a common problem. “Human contact helps the veteran reset abilities,” he said.
Providing in-home behavioral health services does have some challenges, Zuzelo admitted. While you might have an office in which to do paperwork, your car becomes home. His work often “involves two-and-a-half to three hours of travel,” he said. He averages between 35 and 40 miles on the road daily, but sometimes drives more than 100 miles to see clients.
Zuzelo pointed out that home visits to veterans also take an emotional toll on the clinician. “Going into the home can be a compelling situation. How much do I involve myself?” he said. “There are definite treatment boundaries that can be unique to the role.”
Training for this type of work has changed in the last decade, Zuzelo noted. “Ten years ago, grad school didn’t prepare me for this role,” he said. When he joined the VA staff, Zuzelo learned on the job, and admits he has more to learn. “Fortunately, I am really comfortable with the geriatric population so it’s been a good fit.”
While this type of work is not for everyone, particularly psychologists new to the profession, Zuzelo pointed out there are benefits.
“Professionally, as a psychologist, I feel I have really grown in my range of experience. I have better appreciation for the way others interact with the world. The work has stretched my clinical skills,” he said. “It’s rewarding to help patients reconnect on a human level. I do some outpatient work, but it does not have the emotional depth of the experience in the home.”
By Phyllis Hanlon