Ch. 11 Home Visiting

What You Will LearnDefine home visiting and provide examples of when and why

they are conductedPrepare for home visitsIdentify key safety concerns and plan for ways to address

themDiscuss what to do (and what not to do) when you arrive at a

client’s homeConduct a subtle assessment of the home environment, and

explain why this is importantIdentify and respond to common challenges related to home

visiting

An Overview of Home VisitingHome visiting involves meeting with clients

where they live.Could be an apartment, home, trailer, single-room

occupancy (SRO) hotel, a shelter, jail, homeless encampment, on the streets, in the park etc.

Home visiting is one of the most direct and personal ways to work with clients

Why Make Home Visits To visit clients who are unable to come to your office

To follow up with clients who recently received services from your program

To contact clients who have not kept in touch, to see whether they are all right and interested in participating in services again

To see clients who have recently experienced a decline in health

Because family members or friends of a client contact you out of concern for the client and ask you to visit that person

Why Make Home Visits continued To encourage clients to come to your agency for important services

that cannot be delivered at their homes To support new parents or guardians To enable clients to assess their home environments and possible

health risks, such as exposure to mold, dust, or other allergens that cause asthma

To provide support and guidance to clients regarding how to take medication properly

To notify clients that they may have been exposed to an infectious disease and to encourage them to get screened

To meet with clients who are in the hospital, jail, or other institutionsThe Power of Home Visits

The Challenges of Home Visiting Clients may not want you to visit or may not want to talk with you right then Clients may be embarrassed about their living conditions Clients may be concerned about their privacy Clients may worry that you will judge them if they live in nontraditional

families, or they may have other cultural concerns They may worry that you will learn about or expose their immigration status,

or worry that they could lose certain health, housing, or social benefits Clients may have had bad experiences with home visits from child welfare,

social workers, the police, or other authorities You may witness or learn about drug use, neglect, or abuse You may face risks to your personal safety Your clients may be very ill or facing death

Preparing to Conduct a Home VisitPut yourself in the client’s shoes

How might it feel for a stranger to come into your home?

What would you want from the CHW?What would you not want them to do, see, or ask?

Respect a client’s right to privacy-discreet home visitsSome clients may not want others to know they are

working with you/your agency.How do you protect their privacy during home visits?

Ex. “Hey, Bernadette, good to see you today. Is this a good time for a visit?”

Start Things off RightShadow another CHW

Observe what they do & how they interact with clients & their families

Review and Prepare Clients FilesReview client files and key strengths, risks, needs,

and other health concernsCheck to see if referrals were providedBring copies of blank release forms

Organize and Pack Resources to Bring on the Visit Your ID badge & business card

Written info about your agency

Client files, blank new client files, and other forms

Copies of any test results that you are authorized to review with the client

Any medications of tests that your are authorized to bring and administer

Educational materials to use to explain something more clearly

Risk-reduction or other health materials such as condoms, lubricants, hygiene kits, nutritional supplements, food or transportation vouchers etc

A map, phone or GPS in case you get lost

A folding chair or stool

A flashlight

A cell phone

Plan How You Will Travel to the Client’s Home Client’s address Landmarks nearby Public transportation or parking availability Anything you might need to know for your safetyIf you have an appointment, try to determine: If there is a house, apartment, or room number clearly marked If the client has a dog or other pets If there is a gate or intercom at the home or building Any possible problems you may encounter

Identify Key ObjectsWrite down what you hope to accomplish during

the home visitDon’t set too many goals for a single visitYou need to be flexibleTalk with the client to learn their current health

status, needs, and priorities

Preparing to Conduct a First Visit to a New ClientObtain informed consent before you conduct an

initial assessmentCheck to see if client has already signed a HIPAA

formPrimary goals are to establish a positive

connection with the client, assess client’s resources and needs, and to determine whether the person is interested in the services that you can provide

Conducting Home Visits

Preparing for Follow-Up Visits Reintroduce yourself and the purpose of your visit

Review your program’s services

Answer the client’s questions and concerns

Obtain informed consent, again, to continue with your visit and to provide services

Ask what the client remembers about your previous work together

Review any decisions, agreements, or accomplishments that the client previously made

Assess their current concerns, needs and priorities

Establish new goals that the client wants to work on

Provide health education, client-centered counseling, and referrals

Bring medications and assist clients with medications management

Provide additional supplies as needed

Set a date and time for your next visit

Respect the Client’s TimeShow up on time- let client know if you are

running lateDiscuss how much time you both have for the visitIt is the client’s home, the client’s time, the

client’s lifeIf you don’t accomplish all of your goals during the

visit, schedule a follow-up

Announce and Introduce YourselfWhen you arrive at the client’s home, announce

yourself.Use your name but not your agency to protect

client’s identity

Introduce yourself againBe sure to wear proper identificationIf the situation seems uncomfortable, ask the

client if they would like to reschedule

Dress for the OccasionWear appropriate clothing- wear something

comfortable but also culturally appropriateFind out dress code if you’re visiting someone who

is incarceratedUse your own best judgment or ask other CHWs

what they would wear

Practice Cultural HumilityCultures, values, and traditions of clients and

families will be reflected in their homesMany things in their home may be different than

what you are familiar withView home visits as an opportunity to learn more

about other cultureshttps://www.youtube.com/watch?v=lVZ71undTJ0

Speak ClearlyA calming voice can serve to relax othersSpeak loudly enough for the client to hear you,

but not so loudly that you broadcast private info to others

Listen carefully to clients- if you can’t hear or understand what they say, ask them to tell you again

Maintain Healthy BoundariesBe cautious about disclosing personal informationIf a client asks personal questions that you do not feel

comfortable answering, explain and clarify your role as a CHWEx. “My role is to be here for you, to support you to

improve your health. I don’t talk about my private life when I’m at work, because that will distract us-this is your time.”

If a client continues to push at your boundaries, you may have to leave

https://www.youtube.com/watch?v=gBpDwbTsLlE

Stay On TopicPlan for how you will disengage from

conversations that are taking up too much timeBut, be prepared to do some casual visitingSome clients may want to talk for a very long

time- this may be a sign of their isolation and loneliness etc.Develop your own way to politely interrupt clients

and remind them of the time and main purpose for the visit

Overcoming Distractions Media: ask client if it would be possible to turn these off or down so

that you can focus on their needs and concerns Pets: if there is a pet such as a large dog that makes you

uncomfortable, ask if it would be possible to put it in another room Other people: if other people are a distraction, ask the client if it

would be possible to talk privately Drug and alcohol use: do your best to provide the services you are

authorized to provide & be sensitive to informed consent issues. Do not ask client to make life-changing decisions when high. If client has a history of being abusive or violent while high, do not attempt to work under these circumstances

Cluttering or Hoarding: do not make negative comments about the clutter or attempt to move anything- this could upset the client. It is recommended you bring a portable stool to sit on when you conduct home visits

Safety Guidelines for Home VisitsBe aware of your surroundingsDon’t let your bias guide or distort the way that

you assess safety risksTake time to get to know the community you are

working inListen to your instincts- they may be tipping you

off to a dangerous situation

Be Prepared Find out as much info as possible about the client you will visit Find out what type of housing the client lives in and where Find out detailed info about the locations you will be visiting Consider working with a partner in communities that have a reputation

of being risky Let your supervisor know whom you will be visiting, where you will be

going, and when Dress appropriately Avoid agency logos or signage on your car, clothing or anywhere else Bring a cell phone If you will be visiting a client after dark, bring a flashlight

Pay Attention, and Be DiscreetBe discreet when visiting a new locationCarry yourself with secure body languageThe risks to women are different from those of

men- be aware of these risks, and make good decisions to preserve your safety

Be aware of your surroundingsBe ready to think on your feet

If Conflict or Danger ArisesDe-escalate conflict and work to calm the person

involvedApologize: you may have unintentionally done

something that provoked that person’s angerLeave if you don’t feel safeReport and documentOnly call the police if it is absolutely required

How to Conduct a Home VisitIntroduce yourselfConfirm you are talking to the clientBe friendly and patient if other family members

are presentExplain why you are thereAsk if it is still a good time to visit and discuss

what the client would like to accomplish

Conduct and AssessmentDuring each home visit you will conduct some type of an assessment, such as: A client’s knowledge about and interest in a particular service A client’s strengths, risks, and needs in order to develop a risk-

reduction plan A client’s current health status and needs for additional services Adherence to specific treatments such as taking daily

medications for diabetes or HIV diseases A client’s progress with a risk-reduction or case management plan Exposure to environmental health risks

Conducting an Environmental AssessmentYou may observe: Client’s level of stress at home Basic living conditions, including access to clean sheets, clothing,

and resources for hygiene Availability of food Environmental risks such as mold, dust, insect or rodent issues, or

safety hazards for young children The presence or absence of friends, family, roommates, and the

quality of those relationships Challenges with mobility within or outside of the home Exposure to safety risks such as abuse or neglect

Providing Case Management, Client-Centered Counseling, and Health EducationYou may provide health education about a specific

condition-like hypertension or heart diseaseThis may include assessing their levels of

knowledge, providing info, and supporting them in thinking about relevant behavior changes

You may provide client-centered counseling or coaching- including parenting, domestic violence, or depression

Explain the Next StepsClarify and document what the next steps will be

Plan should address all concerns and priorities that client discussed with you

Confirm date and location of next appointmentWrite down plan and leave it for client- if they

cannot read, ask if there is someone who can review it with them

Goodbye and Thank YouTell the client goodbyeThank them again for their time & hospitality

After the VisitComplete paperwork documenting the visit, any

assessment conducted, info you learned, services provided, and agreements made

Write down future appointments or visits in your planner or calendar

Find out info you needed during your visit but did not have, such as specific resources

Check in with the client by phone, with a follow-up visit, or with an appointment at another location

Talk with your supervisor or another colleague about any remaining questions or concerns you may have

Common ChallengesVisits to People Without Traditional Homes

Be as respectful of this space as you would any other home

If client expresses that they do not want you there, leave

Do you best to keep your communication confidential- keep your voice low

If others are nearby and may be listening, do not discuss confidential matters

When Clients are AngryWhile their anger may sometimes be about you,

generally it is about other issues they are confronting, such as experiences of discrimination, violence, mental health conditions, separation, or conflict with family members

Be patient and stay calmStay respectful, professional, and politeIf client acts in ways that are threatening or

physically aggressive and you cannot de-escalate their anger, leave immediately

Working with Clients Who are IncarceratedContact the jail to gain security clearance and ask

what to wearAssist client in making plans for what to do in the

very first hours and days when they are releasedIf clients want to make changes regarding

substance abuse, assist them to figure out what they can do that will reduce their risks of using

You may ask them to call you when they know that they will be released to schedule a time to meet

Workbook pg. 25Motivational Interviewing: “Directive, client-centered counseling style for eliciting behavior change by assisting clients to explore and resolve ambivalence”Doing Client-Centered WorkListen carefully to what the client is telling youClosely observe the client and his/her surroundingsSpeak less and listen more. Are you dominating the

discussion?This does NOT mean that you should always agree with the

client or support everything WAIT- Why Am I Talking?

Workbook pg. 25Attitudes and Behaviors Used in Motivational InterviewingEnhance motivation for change: Respect Empathy Being nonjudgmental Curiosity Genuine interest Collaborative spirit Emphasis on client’s choice Support of client’s autonomy

Workbook pg. 25Promote resistance to change:Arguing, coercing, imposingBlaming, shaming, criticizingJudging, labeling, warningCommanding, threateningMoralizing, preaching, lecturingAssuming the expert role

Workbook pg. 25OARS

Open-ended questionsAffirmationsReflective listeningSummarizing

Open-Ended QuestionsUsing open ended questions allows the client to

talk moreOpportunity for client to talk about feelings,

desires, and fearsListen to these answers without judgment- this

will build trust