Clinician Safety in Home-Based Care

While we imagine most health services taking place in a clinic or an office, many clinicians choose to offer services right in their clients’ homes. Home-based, or in-home therapy, refers to clinicians traveling to and conducting services within the client’s home—and it’s one of the fastest growing modalities of healthcare in the United States. 

Seeing clients in their home environment has several benefits both for your practice and your clients. If you find yourself dreading sitting in an office all day, home-based therapy allows you to travel and really engage with the surrounding community. It allows you to see clients in their “natural habitats.” You might see family interactions play out in who sits where on the couch for a session or who shares a room in the home. 

The Benefits of Home-Based Therapy

Providing services in clients’ homes can also set your practice apart. For example, if you are a mental health clinician who specializes in hoarding behaviors, you will be able to assess safety issues in the home. Other practitioners can use in-home services as well. As a registered dietitian, you can assess the kitchen or the home overall for specific barriers that help inform treatment. 

In-home services also allow clients without access to childcare or eldercare the option to still have in-person therapy. Additionally, it increases access to care for those who are homebound or bed bound, are in rural and underserved areas, or are otherwise not a good fit for telehealth or office-based therapy. Home-based services have also been shown to help build trust in the relationship and can help clients feel more comfortable during services. 

Safety Issues in Home-Based Therapy 

Despite the many benefits for clinicians and for clients, home-based therapy isn’t without its challenges. Entering an unknown space—like a client’s home—can often create an unpredictable environment, which naturally introduces safety issues into the session. 

For example, you might be traveling to rural areas where cell service is spotty or nonexistent, meaning it might be more difficult to contact emergency services. You might also have to consider severe weather events that could threaten your safety while traveling to a client’s home or prevent you from leaving a client’s home.

Then there’s the actual home environment itself that could host a number of potential safety issues. For example, if you offer home-based services, consider assessing the client’s space for unknown visitors, aggressive pets, or even open flames before beginning services. 

Biological issues in the home can pose unique safety concerns for home-based providers. These threats to safety and hygiene can include insects, such as bed bugs or lice, substance use in the home, open chemicals, and, as we all considered in 2020, airborne illnesses. 

Intimate partner violence is another safety concern for home-based clinicians. While a clinician in an office-based setting can determine easily who is and isn’t allowed in the office, a home-based clinician might not be able to control who else is in the home, including strangers or family members. The clinician might also be unaware of the layout of the home meaning another person could be in another room without the clinician’s knowledge. 

In addition to being a safety issue, others in the home might make it more difficult for the clinician to maintain a confidential space. Once in the home, a clinician might struggle to feel comfortable enough to ask a visitor or family member to leave or ask the client to set that boundary in their own home. 

Promoting Safety in Home-Based Care

As in other settings, your comfort levels in the home environment impact services. Clinicians who feel safe are able to focus their attention on their clients. You do your best work as a healthcare provider when you feel safe and you’re able to ensure your client’s safety. 

Despite these potential safety issues, there are steps you can take to promote safety and comfort—starting before you ever enter the home all the way through the time you leave. 

Pack the right tools.

Before entering a client’s home, make sure you have the right tools for the job. A well-stocked first aid kit might be the most important item you bring with you in case of an emergency. In addition to packing a first aid kit you might purchase, the American Red Cross suggests including personal items, such as personal medications and emergency phone numbers, and checking the first aid kit regularly for expired items. 

Closed-toed shoes and breathable clothing can also help you to stay comfortable in these spaces. Because the home environment can be unpredictable, bring a change of clothes in case you are exposed to hazardous materials. In addition to these items, you might also pack water, snacks, hand sanitizer, a portable phone charger, a flashlight, and jumper cables if you drive to your client’s location. 

Set expectations for your arrival.

Before your first visit, call the client to confirm the meeting location and to assess for safety and remind the client of expectations for meetings (like confidentiality). You may ask the client if they expect anybody else to be in the home at the time of your meeting, or if there is any substance use in the home or any suspected illness. 

Once you arrive at the home, park in a well lit area that’s free of obstructions. Park facing the road so you can easily pull out if you need to leave the home in a hurry. When selecting where to sit for your session, always choose a seat closest to the exit, preferably with an alternative exit near if possible. Sitting between two family members could pose another risk should the family become escalated. Keep your phone and your keys easily accessible. 

Assess the home when you arrive.

When assessing the home for the first time, be on the lookout for immediate safety issues. These can include portions of the home that are open to the elements (missing flooring or ceiling), exposed electrical wiring, chemical smells, or open flames. If the client has a pet that is acting aggressively towards you or the client or if you’re allergic, it’s ok to set a boundary and ask the client to separate the pet for the remainder of the meeting. 

The home can provide a variety of contextual information that can help you in treatment planning. The safety issues you note can inform you about what barriers your client faces or even their level of cognitive functioning. Asking the client if they notice any safety issues in the home can help the clinician assess a client’s understanding and/or values about their home environment. 

Plan your emergency exit.

If you notice immediate safety issues in the home or if you notice your client or a family member escalating (i.e. yelling or threatening you or family members or moving closer towards your space), you may need to assess if a boundary has been crossed and the situation becomes non-therapeutic or unsafe. 

Depending on the situation, you can either offer to return once the safety issue has been addressed. In some cases,  it may be better to offer referral sources if you feel home-based services may not be appropriate. You can also try to make an excuse to leave inconspicuously if you need to by stating you have received an emergency text, or something similar. Your safety and your client’s safety is top priority. Sometimes leaving that space can be the safest and most ethically appropriate decision. 

Going into a client’s home can be an exciting and strange new experience for some clinicians. With a safety checklist like this in place, you can feel comfortable in these environments and build a thriving home-based practice that serves your clients and your business.