Professional Psychology: Research and Practice In the public domain

2010, Vol. 41, No. 4, 340 –346 DOI: 10.1037/a0020431

A Model for Home-Based Psychology From the Veterans

Health Administration

Bret L. Hicken Angela Plowhead

George E. Wahlen VA Medical Center, Salt Lake City, UT Portland VA Medical Center, Portland, OR

The changing healthcare environment is creating opportunities for psychologists to practice in

non-traditional settings. This paper describes a Veterans Health Administration (VA) initiative to
integrate psychologists into its Home Based Primary Care (HBPC) program. As psychologists new to
HBPC are learning, the home offers opportunities and challenges not routinely encountered in the
traditional office setting. Home-based psychology offers improved access to mental health services, more
effective treatment planning, and more accurate assessments in an underserved patient population.
Psychologists practicing in this setting also encounter challenges in dealing with patient confidentiality,
distractions, role confusion and boundaries, time management, safety, and professional competency. The
VA experience is an instructive case example for psychologists considering this growing field of practice.
This paper offers lessons learned from this VA initiative and discusses strategies for dealing with
potential challenges.

Keywords: home care, psychology and home based primary care, therapy, assessment, homebound

How do patients receive quality mental health care when they
are homebound? For many, particularly the frail elderly, confine-
ment to home due to physical and/or psychological disability
precludes access to most mental health services. Some mental
health disciplines offer limited home care services, most notably
social work, but psychologists have largely been absent from this
treatment setting. A growing body of research suggests that many
psychological problems could be effectively managed at home.
The literature documents successful home-based behavioral inter-
ventions for depression (Lie, Arnesen, Sandvik, Hamilton, &
Bunch, 2007; Maxfield & Segal, 2008), anxiety (Lie et al., 2007;
Rowa et al., 2007), and health-related conditions such as diabetes
(Ellis et al., 2005; Naar-King, Ellis, Idalski, Frey, & Cunningham,
2007), heart disease (Doering, Cross, Vredevoe, Martinez-Maza,
& Cowan, 2007; Lie et al., 2007), HIV/AIDS (O’Hare et al., 2005;
Rotheram-Borus et al., 2006), and traumatic brain injury (Sanford
et al., 2006; Warden et al., 2000). Importantly, treating mental
BRET L. HICKEN received his PhD in clinical psychology from University
of Alabama at Birmingham. He is a psychologist with the George E.
Wahlen VA Medical Center and a researcher with the VA Rural Health
Resource Center-Western Region in Salt Lake City, UT, and an adjunct
professor in the Department of Counseling Psychology, University of Utah.
His areas of research and practice include geropsychology, capacity eval-
uation, dementia assessment/treatment, rural health, and caregiver support.
ANGELA PLOWHEAD received her PsyD in clinical psychology from George
Fox University. She is a psychologist and HBPC Mental Health Director at
the Portland VAMC. Her areas of research and practice include geropsy-
chology, capacity evaluation, dementia assessment/treatment, graduate and
postgraduate training, and administration.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Bret L.
Hicken, VA Rural Health Resource Center-Western Region, VA Salt Lake
City Health Care System, 500 Foothill Dr. (182), SLC, UT 84148. E-mail:
bret.hicken@va.gov
health problems in a patient’s home may also prevent future
psychiatric hospitalization (Behrens, 1967).
In 2007, the Veterans Health Administration (VA) Office of
Mental Health Services began offering home-based psychological
services through its Home Based Primary Care (HBPC) programs.
Launched in 1972, HBPC provides longitudinal, comprehensive,
and interdisciplinary primary care in the homes of veterans with
medical, social, and behavioral conditions too complex for man-
agement through clinic-based care (Department of Veterans
Affairs, 2007). These interdisciplinary teams are headed by a
physician medical director and, traditionally, a nurse or social
worker serves as program manager. In addition to medicine, nurs-
ing, and social work, HBPC clinical staff typically includes other
allied professions such as pharmacy, occupational therapy, and
dietetics. Though HBPC is not exclusively a geriatrics program, the
demographics of the VA and of the home care population in general
result in a patient population in HBPC with a mean age of 76.5 years.
The typical HBPC patient also has eight or more chronic medical or
psychological conditions and 47% are dependent for 2 or more
activities of daily living (ADLs). Forty-seven percent of HBPC pa-
tients are married and 29% live alone (Edes, 2008).
Recognizing an unmet need for mental health services in the
HBPC patient population, the VA provided funding to over 100
HBPC teams nationwide for the purpose of hiring a full-time
psychologist. The VA targeted psychologists for hiring with the
expectation that they could provide more comprehensive mental
health services than are offered from other disciplines that provide
counseling (e.g., social work, chaplain services, etc.). Psycholo-
gists’ expertise in cognitive and personality assessment and
evidence-based treatments was particularly needed for this popu-
lation in which cognitive and psychiatric disorders are so preva-
lent.
The initiative favored the psychologist’s functioning in an inte-
grated, collaborative role rather than in the consult/liaison role

340
 PSYCHOLOGY IN THE HOME
traditional to most primary care settings (Todahl, Linville, Chou,
& Maher-Cosenza, 2008). As such, the psychologist is a core
member of the HBPC team and provides direct patient care,
contributes to treatment planning for each patient, and assists other
providers in achieving treatment goals (Zeiss & Karlin, 2008).
HBPC psychologists’ broad role is to integrate mental health into
HBPC, with specifics of how to do this left to local HBPC
programs. As such, psychologists developed their roles within the
context of their own teams.
HBPC psychologists provide psychological assessment, cogni-
tive screening (including dementia screening and capacity assess-
ments), and evidence-based psychosocial intervention and preven-
tion services. Psychologists may also provide treatment for
subclinical mental health problems, bereavement, adjustment dif-
ficulties, substance abuse, and health-related concerns such as
pain, sleep disorders, and overweight/obesity. They also provide
limited services to caregivers of HBPC patients. Finally, psychol-
ogists promote communication between HBPC team members,
patients, and their families to facilitate medical treatment (Zeiss &
Karlin, 2008).
Providing psychological services at home creates several unique
opportunities and challenges that are not routinely encountered in
other care settings in which psychologists typically practice, in-
cluding other primary care environments (Blass et al., 2006).
Psychologists must be aware of these potential issues in order to
work effectively in this setting. However, the literature offers little
guidance for psychologists practicing in the home. The HBPC
psychologist initiative is an instructive case example of how some
psychologists deal with these issues. Psychologists’ experience
within this program holds promise for adding to the literature on
home-based psychology. Though mental health care within the VA
differs from other settings in which psychologists practice, many
of the opportunities and challenges described in this paper would
likely be common to most home settings, regardless of context.
This paper highlights opportunities and challenges HBPC psychol-
ogists have encountered while seeing veterans in their homes and
provides suggestions for working in this clinical setting.
Lessons From the VA
Opportunities
Improved access to treatment. Besides the obvious advan-
tage of providing mental health care to veterans who otherwise
lack access, the HBPC psychologist initiative enhances access in
other ways. Service in the home may increase acceptance of
psychological intervention in patients who would normally be
resistant to outpatient mental health services due to the stigma
attached to receiving mental health care (Choi, 2009; Todahl et al.,
2008; Wehry, 1995). Patients seen at home may also feel a greater
sense of empowerment in therapy than they might in a clinic
setting (Gerace et al., 1990; Reiter, 2000; Synder & McCollum,
1999). In the office, the line of demarcation between patient and
clinician can make patients with trust issues reluctant to confide in
a therapist and they may adopt a passive role in therapy (Woods,
1988). The comfort of one’s home, in contrast, raises patients’
sense of control (Reiter, 2000; Woods, 1988) and fosters an
egalitarian relationship, thus helping establish a therapeutic alli-
ance (Behrens, 1967; Reiter, 2000; Woods, 1988). HBPC psychol-
341
ogists commonly encounter patients who, despite many previous
refusals of office-based mental health services, accept a psychol-
ogist house call and succeed in psychotherapy within the privacy
of their own homes.
Within HBPC, psychological intervention may be particularly
acceptable because the psychologist’s membership on a trusted
case management team confers added legitimacy to some patients.
Indeed, resistant patients may sometimes be “prodded” to accept a
psychologist visit with encouragement from their HBPC medical
provider. A psychologist home visit can also promote a feeling of
being valued by the medical system in some patients (Todahl et al.,
2008). Finally, the psychologist’s relationship to the larger treat-
ment team may also reduce the chance of patients terminating
therapy prematurely (Todahl et al., 2008).
Improved treatment planning. Adherence to medical treat-
ment falls dramatically after the first 6 months and is particularly
poor in patients with psychiatric disorders (Osterberg & Blaschke,
2005). However, home-based care improves adherence to medical
treatment plans (Berrien, Salazar, Reynolds, & McKay, 2004;
Krebs et al., 2008) and may also improve adherence to behavioral
interventions (Waters & Ross, 2004) for several reasons. First,
observing the family at home offers insights into family dynamics
and culture that could affect eventual behavior change (Gerace et
al., 1990; Reiter, 2000; Woods, 1988). One HBPC patient, for
example, requested assistance with smoking cessation but the
psychologist’s visit revealed five other smokers in the home and a
very small living area that would not permit segregation of smok-
ers from non-smokers. The psychologist presented these factors to
the patient, family, and the HBPC team, which fostered a discus-
sion about ways to facilitate smoking-cessation and helped the
patient and HBPC team set realistic expectations for success.
Home visits also allow the psychologist to evaluate factors that
maintain homeostasis of the family system (Woods, 1988) and
how an intervention might upset existing relationships. For exam-
ple, one veteran’s wife complained about feeling trapped in caring
for her chronically ill husband who required constant supervision.
However, she had previously resisted all legitimate options for
respite. Eventually she divulged to the psychologist that caregiving
had a side benefit of effective distraction from her own emotional
problems that she did not wish to confront. Thus, she was invested
in maintaining her husband’s dependence on her by not forfeiting
caregiving to others. Understanding this dynamic permitted a more
open discussion of her resistance.
Home visits may also allow the psychologist to enlist other
family or friends into planning and monitoring psychological
interventions (Behrens, 1967; Reiter, 2000; Woods, 1988). These
individuals can provide collateral information about the patient’s
mood, behavior, and history and they can be directly involved in
treatment planning and care coordination (Behrens, 1967). They
often provide functional support, such as transportation or meal
preparation. Family members also offer a different perspective
from the patient about how an intervention affected the patient and
the family system. Drawing the caregivers into treatment planning
helps ensure that recommendations are not over taxing the pa-
tient’s support network. The home visit will also reveal a caregiv-
er’s own capacity to assist in implementing the treatment plan
(Behrens, 1967; Woods, 1988). HBPC psychologists commonly
encounter caregiving spouses with their own cognitive problems,
which often explains why previous interventions have been un-
342 HICKEN AND PLOWHEAD
successful. With a home visit, in short, treatment planning is made
with better awareness of the patient system, which may increase
the likelihood of meeting treatment goals.
Caregivers may also be receptive to treatment in their homes as
caregiving responsibilities often make it difficult to seek assistance
elsewhere. The caregiver of one veteran, for example, was arrang-
ing to place her father in a nursing home because of his sexual
disinhibition secondary to progressing dementia. The veteran lived
in her home and she felt threatened and disgusted by his behavior.
The HBPC psychologist evaluated the patient and met with her in
her home. Over several sessions they developed a behavior plan to
address the problem. Through these meetings, she developed a
better understanding of her father’s disease and was able to mod-
erate her expectations for his behavior. Her confidence and capac-
ity to deal with his inappropriate behaviors improved. With
“booster” sessions every few months, the veteran’s sexual behav-
iors declined as did his daughter’s frustration and he was able to
remain at home.
Improved reliability and validity. Though the controlled
office environment helps promote a sense of calm and safety,
patients’ behavior therein may not generalize to the “real world”
(Woods, 1988). Patients’ day-to-day functioning can be more
easily examined in the naturalistic setting of the home (Gerace et
al., 1990; Woods, 1988). Patients’ interactions with loved ones, for
example, are an invaluable source of data often unavailable in the
office (Behrens, 1967). One HBPC psychologist seeing a couple
for marriage counseling noted that they rarely displayed typical
signs of intimacy (e.g., sitting close to each other, holding hands).
However, because therapy occurred at home, the psychologist
observed other casual behaviors that conveyed intimate feelings
(e.g., a hand on a shoulder after getting a cup of coffee for the
other) that may have been less likely to occur in an outpatient
office.
Direct observation of the patient’s living environment often
reveals secondary information helpful in evaluating the reliability
of patient self-report. For example, patients often overestimate
their adherence to medications (Osterberg & Blaschke, 2005). At
home, HBPC psychologists may check the pill box against patient
self-report to identify missed doses that may indicate undetected
cognitive problems, which can help reduce medication errors and
improve effectiveness (De Smet, Denneboom, Kramers, & Grol,
2007). Such observations can also lead to tailored recommenda-
tions and referrals to other services (Reiter, 2000).
Home visits are particularly valuable in capacity evaluations,
which would typically be conducted in the office where only a
best-guess assessment of actual functioning can be made. Con-
ducting the evaluation in the specific environment in which the
patient most often functions provides the examiner with informa-
tion that the patient or family may minimize or think unimportant.
For instance, the psychologist can see if the home is well main-
tained or if living conditions are substandard or unsafe. More
importantly, the psychologist can assess whether patients are
aware of safety issues and can evaluate their strategies for dealing
with unsafe conditions such as loose floor boards on a staircase,
clutter, or unrefrigerated food. For example, one HBPC veteran
lived in a one room cinderblock home heated by an open grate
fireplace and two propane-fueled heaters, the tanks for which sat
next to the fire. The psychologist’s evaluation revealed that the
patient did not understand the potential danger of this arrangement,
which informed the psychologist’s assessment that the patient
lacked the capacity to live independently.
Challenges
Confidentiality. Maintaining confidentiality is a common
challenge in home care (Blass et al., 2006; Synder & McCollum,
1999), because the familiar nature of the home can make it difficult
for some patients and family members to understand the necessity
for privacy when discussing some personal matters. Threats to
privacy are compounded by caregivers who feel responsible for
knowing everything about the patient’s treatment (Petrila & Sad-
off, 1992). While some family members will excuse themselves at
the beginning of a session, others are reluctant to leave their loved
one. Conversely, patients may allow family members to remain
during a visit, but may not anticipate the personal nature of some
questions. Friends, houseguests, homemakers, aides, and other
medical staff are also frequently present during scheduled visits.
One must also be wary of the “illusion of privacy” during a
home visit. Even when others leave the room to allow some
privacy, sessions can be overheard from other rooms, particularly
if the psychologist must speak loudly for a patient who is hard of
hearing. Strained relationships between patients and family in
some households underscore the importance of psychologists at-
tending to this issue. Family members of one HBPC veteran, for
instance, “hovered” just outside the living room where sessions
were held, and frequently walked through the room on their way to
other parts of the house. The veteran was understandably reticent
about discussing feelings about family members. In this case,
sessions were scheduled at times when the veteran was home alone
or were moved to the back porch, a much more private location.
Some HBPC psychologists have also purchased white noise ma-
chines to block out conversation and personal voice amplifiers
with patient headphones to reduce the need to speak loudly during
sessions.
Confidentiality issues can be particularly difficult to navigate in
a patient’s home where the psychologist is a guest. As already
noted, the balance of power normally experienced in the outpatient
office setting is equalized in the home (Mueller & Leviton, 1986)
so the psychologist has less control over the session and may feel
less comfortable asking family members to leave (Mueller &
Leviton, 1986; Synder & McCollum, 1999). Some family who
would comply with a request for privacy in the office may require
more explanation and assurance when this same request is given in
the home. Patients themselves often need reminders about the
importance of confidentiality. To one hard-of-hearing veteran, for
example, the HPBC psychologist had to explain the reasons for
confidentiality and why the visit should not be held on the patio
within earshot of neighbors in their yard just a few feet away.
Maintaining confidentiality becomes a particular challenge
when a patient discloses an incident that is “reportable” according
to agency policy. For example, one veteran confided a recent fall
to the HBPC psychologist but then asked that it not be reported to
her HBPC provider. However, HBPC policy at that particular VA
medical center required home care staff to report all falls for safety
reasons, which was explained to the patient. While initially a major
blow to the therapeutic relationship, the incident ultimately pro-
moted a useful discussion about trust and patient safety, which
 PSYCHOLOGY IN THE HOME
eventually led to a stronger, more trusting, and productive rela-
tionship.
Psychologists practicing in the home must proactively mitigate
potential threats to confidentiality. In most HBPC programs, the
limits of confidentiality are explained when the patient is admitted
and signs a release of information agreements to allow providers to
discuss medical information with identified family members or
caregivers. In addition to this “blanket” introduction to confiden-
tiality, HBPC psychologists explain the sensitive nature of inter-
view questions and therapy at the first visit with reminders there-
after whenever potential threats to confidentiality emerge. As with
any new patient, HBPC psychologists discuss the limits of confi-
dentiality but they must also explain any reporting requirements
specific to that setting. Establishing the expectation for confiden-
tiality early on by asking other people to leave the room during
sessions or rescheduling if a potential threat to confidentiality
cannot be eliminated helps to preempt a more serious problem in
the future.
Distractions. As a guest in the patient’s home, the psycholo-
gist carefully navigates what is and is not an acceptable environ-
ment for treatment or testing (Synder & McCollum, 1999). Psy-
chologists practicing in the home usually do not have the luxury of
creating an environment free of noise and other distractions. Other
people, animals, television, radio, telephone calls, even odors and
home cleanliness can create distractions that interrupt or even
prevent a therapy or testing session. It is not unusual, for example,
for the telephone to ring in the middle of memory testing, which
threatens standardized administration. On one occasion, psycho-
therapy with a veteran was interrupted by a phone call from his
angry sister, who yelled at him for several minutes before hanging
up. The focus of therapy, which had been on his traumatic combat
history, was immediately redirected towards processing this phone
call.
Psychologists can help mitigate potential distractions at the
outset of every visit by, first, explaining the importance of a
distraction-free session. This explanation can help patients feel
better about disconnecting the phone, turning off the television, or
moving a pet to another room. Where possible, the psychologist
should select a quiet meeting space and arrange seating (e.g.,
patient’s line of sight away from a window). Set cell phones and
pagers to silent mode. Since clocks are often not placed in conve-
nient locations, psychologists can set a discreet alarm on a cell
phone or other device to avoid checking the time on a watch. When
this standard is set, the patient and other people in the house will
often prepare for sessions by removing potential distractions be-
fore the psychologist arrives. When distractions do occur, the
psychologist’s flexible response can be a model for patients who
have difficulty coping with minor upsets.
Role confusion and boundaries. Home visits foster a level of
familiarity with patients that is uncommon in the office. Some
patients may view the psychologist as a visiting friend rather than
as a clinician (Mok & Chiu, 2004) and will sometimes make
inappropriate requests (e.g., invitations to family events, requests
for help, etc.). For instance, an HBPC social worker once spent an
entire visit trimming the bushes at a patient’s home. Sometimes
patients may wish to spend the session in small talk rather than
working in therapy. Polite offers of a glass of water, refreshments,
or small gifts can also create discomfort for visiting psychologists
unaccustomed to such behavior in the office. This level of famil-
343
iarity sometimes creates pressure for psychologists to divulge
details from their personal lives. Sometimes, observing a patient’s
poor socioeconomic status or a chaotic home situation leads to
psychologists’ feeling obligated to intervene more directly to ad-
dress material needs.
Boundary and role problems are dealt with in much the same
way as they would be in the office. Clarifying the referral question
with the ordering provider before making a visit can help eliminate
some of this confusion. The psychologist should explain the pur-
pose of the visit at the outset and develop therapy goals early on.
Establishing appropriate boundaries early in the relationship and
re-establishing them as that relationship develops is essential for
avoiding problems. Being familiar with and paying close attention
to familial, ethnic, and religious cultural norms when in the home
can help to maintain boundaries while respecting the patient and
establishing a therapeutic alliance (Reiter, 2000). Psychologists
must also attend to their own feelings as the patient-clinician
relationship develops over time. Psychology’s professional stan-
dards for boundaries may differ from those of other health profes-
sions so consultation with other psychologists is particularly help-
ful in dealing with boundary and role issues.
HPBC psychologists can refer patients to other team members
(e.g., social workers) or VA resources to address veterans’ non-
psychological problems. They should also remind patients about
psychology’s role in relation to other providers to explain why a
referral is being made. Some psychologists also carry information
about community agencies to give to patients with needs that
cannot be addressed through behavioral intervention. Federal law
and station policy also provide a simple reason for refusing inap-
propriate requests or gifts. Some HBPC psychologists also conduct
in-service trainings with HBPC teams to develop common stan-
dards for boundaries so that all staff set appropriate limits with
patients.
Time management. Psychologists must factor in travel time
when making home visits. Often, they drive the equivalent of
several commutes each day and unforeseen traffic delays can
disrupt a scheduled appointment. In some instances, these disrup-
tions harm an already tenuous therapeutic relationship. Some psy-
chologists circumvent this issue by giving a time range in which
they will arrive for an appointment, but this strategy can also have
pitfalls, particularly when a patient has preexisting issues of dis-
trust with the medical system. Psychotherapy sessions in the home
typically last longer than the 50-minute hour typical of an office
visit (Synder & McCollum, 1999), which must also be factored
into scheduling.
Home care psychologists must carefully select which patients
they see at home—visiting inappropriate referrals creates un-
needed time pressure and can quickly outstrip psychologists’ avail-
ability. When first starting on HBPC, many psychologists met with
the team to educate them about which problems are appropriately
handled by psychology. Many psychologists have delegated se-
lected clinical activities, such as cognitive screening and some
therapies, to other HBPC providers, leaving the psychologist avail-
able for more complex cases. Clarifying the referral question
sometimes eliminate the need for a visit altogether. For example,
one HBPC nurse requested cognitive testing for two patients prior
to starting them on donepezil for dementia. However, after dis-
cussing each patient’s advanced symptoms, the nurse and psychol-
344 HICKEN AND PLOWHEAD
ogist agreed that cognitive testing was likely to be uninformative
and the consult was withdrawn.
Safety. Homecare workers sometimes work in high crime
areas; face adverse driving conditions; deal with patients, family,
and caregivers who are active substance abusers; and experience
violence directed at them and others while in the home (Freed &
Drake, 1999; Ungvarski, 1996). Every HBPC program has safety
polices to mitigate potential safety threats. Common elements
include 1) conducting joint visits with another staff member in
potentially unsafe areas; 2) requiring homecare staff to carry cell
phones; 3) leaving visit schedules with the homecare office to aid
in tracking staff location; 4) discharging or refusing to accept
patients who may be a danger to staff; 5) hiring escorts to accom-
pany staff to and from visits.
Most HBPC teams screen for potential dangers such as firearms
or pets prior to admitting patients and safety threats may affect
whether patients are admitted to the program. Most HBPC teams
also meet weekly to review patient progress and to address dan-
gerous situations before they escalate. Each VA facility also has a
Disruptive Behavior Committee that can assist staff to evaluate
and manage possible threats (Department of Veterans Affairs,
2007). VA clinical staff also receive annual training on how to
identify and defuse potentially dangerous situations and on how to
extricate themselves from violent situations (Department of Vet-
erans Affairs, 2007).
Competence. Competence standards and practice guidelines
for home-based psychology have not been established. The Amer-
ican Psychological Association (APA) has published guidelines on
working with older adults (APA, 2004) and primary care psychol-
ogy (APA, 2009), which are informative to HBPC psychologists.
But none of these guidelines accounts for of the unique challenges
outlined above or the breadth of psychological disorders encoun-
tered in the home setting.
In many respects, the HBPC psychologist functions similarly to
a psychologist practicing in a rural area with limited access to
mental health resources. HBPC psychologists encounter diverse
referral questions about issues like differential diagnosis of de-
mentia, safety concerns such as a patient smoking while on oxy-
gen, hospice and palliative care for patients with terminal diag-
noses, grief work for patients who have lost loved ones, or couples
therapy when marital conflict impacts the health of a patient.
Problems seen in HBPC patients run the gamut from PTSD,
substance abuse, schizophrenia, and dementia, to compliance prob-
lems, pain management, and obesity. It is not uncommon for
patients to have an extensive history of serious mental health
problems prior to admission to HBPC. Consequently, HBPC psy-
chologists often encounter patients that may stretch the limits of
their expertise. In the hospital or clinic, a psychologist might refer
such patients to specialty mental health services. For example,
most large VA Medical centers have PTSD treatment programs for
combat veterans that coordinate individual and group therapies
with medication management. However, many HBPC patients are
homebound and cannot access specialty mental health through the
VA or community.
When home care psychologists do not feel competent to provide
specialty mental health, they should help homebound patients
identify ways to access that care elsewhere. Alternatively, they
may also seek out additional training and consultation with other
psychologists for help with unfamiliar clinical issues, as stipulated
in the APA Ethics Code (APA, 2002). Most HBPC psychologists
are also part of the medical center’s psychology or mental health
service and many psychologists have established consultative re-
lationships with mental health teams in order to facilitate discus-
sion of complex cases. The VA also provides a listserv, monthly
conference calls, and annual conferences where HBPC psycholo-
gists can receive specialty training and advice from colleagues.
Models for training psychologists for home care are not pub-
lished. Two models for mental health training in home care have
been described in the literature but neither is widely cited (Gerace
et al., 1990; Synder & McCollum, 1999). Prior to 2007, training in
this setting was largely unavailable to psychologists. Through the
HBPC psychologist initiative, a supervised experience in home
care psychology is now available to trainees. Supervising psychol-
ogists must document levels of responsibility for all trainees and
often provide more intensive supervision than might be experi-
enced in other settings. The supervisor must accompany practicum
students on all home visits. Interns and fellows make solo visits
once clinical proficiency and training are documented but may still
access the supervisor by phone or pager. Supervision issues are
also frequently discussed over the listserv and conference calls.
Conclusions From the VA Experience
Practicing psychology within the milieu of HBPC is different in
three major ways from practice in some other settings, particularly
noninstitutional ones. First, within the VA, billing and reimburse-
ment are a non-issue for clinicians, and psychologists are usually
not limited by the constraints of visit or reimbursement limits
imposed by third party payers. As salaried employees, they do not
consider the reimbursement amount for the services they provide.
However, each home visit must still be documented and coded,
and finding the right codes to capture workload has been a chal-
lenge. In part because of this initiative, new CPT codes are being
developed to uniquely capture the work done in the home by
psychologists.
Second, institutional characteristics of the VA have supported
HBPC psychologists in developing home-based practices. The VA
funds the psychologist initiative and much of the training recom-
mended above. At most VA medical centers, there are many staff
psychologists available for consultation and mentorship. Psychol-
ogists who are independent practitioners may have to work harder
to find the training and to establish consultative relationships.
Working within an agency is not without challenges, however.
Joint Commission heavily regulates HBPC programs and every
VA has additional policies guiding home care and mental health,
which can be a challenge to address in practice. An independent
provider practicing in the home would presumably have greater
freedom from such administrative requirements.
Finally, this case management program offers advantages for
developing rapport and comprehensive care that may not be ac-
cessible to a private practitioner. This paper has highlighted sev-
eral advantages that membership on the HBPC team provides to
psychologists. Furthermore, a significant part of an HBPC psy-
chologist’s work is consultation with other HBPC team members,
a time constraint that may not occur in other settings. Also, the
patient population in HBPC tends to be older and predominantly
male, which may be uncharacteristic of other home care settings.
With the influx of new veterans from recent conflicts in the Middle
 PSYCHOLOGY IN THE HOME
East, this demographic will certainly change, creating a new set of
challenges for HBPC psychologists.
It is also important to note that potential opportunities and
challenges described in this article are from a provider perspective.
It is highly likely that patients perceive different pros and cons to
treatment at home. Indeed, the occupational therapy literature
documents this clearly (Stephenson & Wiles, 2000). For example,
home care patients may prefer longer treatment and follow-up than
is provided through a structured intervention (McWey, 2008).
Home-based psychology is part of a larger movement in the
United States to improve access to mental health treatment (Choi,
2009). While the HBPC psychologist program is unique in some
ways, the opportunities and challenges cited in this paper are likely
inherent to any home-based psychology practice. In particular, this
program offers insights into strategies for dealing with difficulties
of delivering psychological care in the home. Psychologists enter-
ing this practice setting will encounter significant challenges that
demand creative solutions. Research is needed to describe these
challenges across different home settings and to develop compe-
tency standards and ethical guidelines specific to this environment.
Nevertheless, home psychology represents an exciting and fulfill-
ing area of practice for psychologists for years to come.
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Received March 25, 2010
Revision received May 13, 2010
Accepted May 14, 2010 䡲