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Who Says “Home Visits” are a Thing of the Past?

Annette Conway, Psy.D.

My interest in specializing and working with the older adult and elderly population began as an undergraduate student at San Diego State University. It was there that I chose elective courses which focused on the sociology and psychology of the aging population. As well, I was fortunate enough to be mentored by two professors, who themselves were older adults.

To gain clinical experience working with the older adult population, I contracted with a home-based organization in 1993, treating clients in their homes who would otherwise not be able to access mental health services, due to being bedbound, homebound, or unable to access transportation, among other reasons. In-home therapy was not only intrinsically rewarding in helping clients bring back purpose to their lives, but I also envisioned its value in helping improve the quality of mental healthcare in San Diego. The increasing need for “home visits”, changes in Medicare reimbursement, technology, and an interdisciplinary team approach influenced the decision to generate an organizational model around these services, known today as Help Therapy.

For the past 29 years Help has been able to assist a large number of individuals, couples, and families who would otherwise have been unable to obtain treatment. Although lack of funding can be a major limitation in accessing mental health services, the issue of actually getting to an office is also a primary hindrance to treatment. As well, video visits require patients to have access to a computer, to be able to get on-line, and fix any technical problems that may arise.

Help Therapy employs approximately 200 providers, including licensed Psychologists, licensed Social Workers, LMFT’s, Neuropsychologists, and Psychiatric Nurse Practitioners, all connecting to patients according to their expertise and geographical location. Help accepts Medicare, Medi-Cal, all PPO Insurances, some HMO’s, contracts with home resource organizations, private pay, and sliding scale fees.

Historically, “home visits” aka “house calls” were not considered a valid clinical option for clinical transference reasons. Psychoanalytic-oriented practitioners and risk management experts were, and many still are, likely to frown upon treatment that departs from the office setting. With the Civil Rights movement of the 60’s and 70’s, and the Passage of Public Law 96-272, also known as the Adoption and Child Welfare Act, home-based family therapy became more common. The law was enacted to increase the safety of foster children and avoid their out-of-home placement. Thus, social workers routinely assessed child abuse and neglect, and domestic abuse in the home.

Today’s elderly population is a special case, as they grew up in an era when psychological help was not only uncommon but was looked down upon.

Needing mental help meant needing a locked room with padded walls. Therefore, the elderly tended to hold a more skeptical, stigmatized view of psychological services.

Ironically however, the older adult and elderly population happens to be most affected by depression and therefore more often are in need of mental health services. Untreated depression has severe implications for older adults. It doubles the risk of developing cardiac disease, reduces the ability to rehabilitate, and increases the chances of dying from illnesses. Furthermore, it is more likely to lead to suicide than in any other age group. In 2020, suicide rates were highest among adults 75 to 84 years (18.43 per 100,000), with the highest among adults 85 years or older (20.86 per 100,000). Overall, depression affects nearly 7 million Americans over the age of 65, but only ten percent receive treatment. Information from the Cleveland Clinic Foundation cites both stigma and the belief that there is no help as reasons why many older adults and elderly do not seek treatment for depression. As well, too often older adults have physical disabilities that distract them from addressing their psychiatric needs.

In-vivo treatment methods utilized at home capture the environment and the dynamics of the family firsthand. A “home visit” serves to support or question the hygiene, organizational abilities, cultural and religious customs, and daily rituals of a client. The “home visit” can help to establish treatment goals while utilizing client strengths and validating a client’s report about their perceptions and coping abilities.

As the therapist crosses the threshold of the client’s home, it is important to realize the subtle and yet ever-present impact of the threshold as a therapeutic factor in the treatment process. The home environment may be reconstructed to a degree in the therapist’s office, however, upon entering the home, the therapist becomes a part of the family with boundaries and many other issues arising as a result. It is this arrangement that increases the likelihood for successful therapeutic contact with homebound individuals, and the benefits that results from a “home visit” intervention.


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