bringing structure to home-based psychological services for people with disabilities
Psychologists are increasingly being called upon to deliver services in a manner that is both flexible and fit-for-purpose. The disability sector is one such area where home-visits are part of flexible service delivery. In this blog, I discuss why home-based psychological services, whilst embracing flexibility, must prioritise structure, to ensure better client outcomes.
A brief guide to sector specific terminology for psychologists working outside the NDIS system:
(a) The words “disabled person/people” will be used in this blog, consistent with terminology preferred by the disability community.
(b) The NDIS is the largest scheme under which services are provided to disabled people in Australia, so this blog will refer to “clients” as “participants” to reflect NDIS appropriate language.
Home-visits by psychologists in the disability sector - why is it needed?
-To make psychological services more accessible to a broader demographic. This could be NDIS participants living in regional areas, participants with specific mobility needs that a brick and mortar clinic may not be fully equipped to manage, participants with sensory needs such as difficulty coping with noise levels and proximity to people in conventional waiting rooms, and so on. It also makes service provision cost-effective because travel fees are covered by the NDIS.
-To anchor assessments and interventions to participants’ everyday environment. Observations of participants in their home environment provides rich data regarding the severity of their symptoms and functioning. Participants also report feeling less anxious about sessions and are more likely to attend sessions regularly. At times, problem-solving skills, distress tolerance, and graded interventions may be easily set up using readily available cues in the participant’s home environment.
The case for well designed and intentionally deployed processes for home-visits
Working with disabled people typically involves working with multiple people and agencies at various stages of the assessment and treatment process.
For example, appointments could involve support workers or family members/informal advocates being present at sessions to provide cognitive assistance such as making notes on strategies or home work being discussed if the participant has difficulties with working memory and attention; administrative assistance such as assistance with sign offs on paperwork or providing access to past reports; and therapeutic assistance such as being trained in emotional regulation skills along with the participant, in order to prompt and reinforce participants outside of sessions.
Thus the participant’s care network typically consists of people with divergent skill sets (e.g. varying mental health training) and experiences (e.g. lived experience of disability themselves).
While everyone involved in the participant’s life is committed to improving their mental health, without the anchor of a well designed process that is deployed by the psychologist in a manner that is intentional, flexible service delivery can quickly turn into a chaotic clinical experience for the participant.
Key elements of home-visit based psychological services for disabled people
Before the appointment
-Know who will be present at the appointment and prepare them. For example, carers or advocates may not be aware that psychology sessions take up to an hour or hour and a half and that they will need to prepare for that shift accordingly. They may also need to be informed about why their input/involvement is being sought as well as privacy and confidentiality norms that they will need to adhere to.
- Paperwork will need to reflect who will be present for sessions and why, such as information from the support coordinator or other referrer about the participant’s clinical presentation and unique needs that make it important for others to be present.
-Preparing the physical space where the session will take place. The participant or their support coordinator may need to prepared in advance that a quiet, private space will be needed to conduct sessions. If a cognitive assessment is to be conducted, it is important to enquire about testing conditions - space, light, noise, need for a desk and chairs, seating position, etc. The participant may need this information to prepare children in the family or other members so that they have a quiet space on the day. If the participant’s physical space is unsuitable either due to issues such as hoarding or ongoing family violence or any other concerns regarding safety, alternative venues will need to be explored in advance.
At the first appointment
-Checking with the participant to get active consent to have others present at the session. Orient participants to what the session will involve and why it was suggested that others be present at the session. Seek active consent and record it in the paperwork.
-Setting the tone for the session - who talks and when, what patient privacy and confidentiality looks like. Discuss session process, who the session will focus on first, when others may provide input, how to contact the psychologist to coordinate future appointments or share relevant reports, potential risk of being privy to the participant’s personal history that is traumatic, and so on.
Subsequent appointments
- Reiterating norms and re-obtaining consent from the participant if there is a different carer involved that shift.
-Seeking regular feedback on how home-based service delivery is working for the participant and accordingly making changes.
Whilst this blog provides a primer on process issues to consider before providing home-based psychological services, there is much to be discussed on this topic. As more psychologists start to provide psychological services under NDIS funding, I predict that professional bodies will further formalise skill building, practice guidelines, and risk management in the area of home-based service delivery for disabled people.