home visits counselling

The Benefits Of In-Home Mental Health Therapy Services For Wellness

Some individuals may be interested in receiving face-to-face support from a mental health professional without traveling to a therapist's office. Barriers like a lack of reliable transportation, difficulty assuring childcare, or mobility challenges can all make it difficult to seek help in an office setting. However, individuals can receive in-person help from the comfort of their homes through in-home or home-based mental health services.  

In-home mental health services involve trained professionals visiting your home in person. These services may benefit those who can't seek in-person appointments or are more comfortable in their own homes. In-home therapy can treat a range of common mental health challenges. Understanding this therapeutic option can help you or a loved one make an informed decision on the options available. 

What are in-home mental health services?

In-home mental health services, also called home-based therapy, are therapeutic services where a professional provides psychological support and treatment within a client's home rather than at a therapist's office. These services can help individuals who may want support but face barriers to traditional options. One-on-one practice therapists and other mental health professionals may offer in-home sessions as an alternative to office sessions.

Benefits of in-home therapy

A potential benefit of in-home therapy is its convenience and availability. Clients don't need to travel to a therapist's office, making it a convenient option for those with mobility challenges, lack of transportation, or childcare concerns. 

In-home therapy can reduce the worry and stress of visiting a mental health facility for some people. Clients may be more comfortable and comfortable with their therapist in a familiar environment. This comfort may strengthen their relationship with their therapist, allowing therapy to be more effective.

In-home therapists may gain a more comprehensive view of the client and their life, allowing them to create a more customized treatment plan. In-home therapy can let therapists learn more about their clients' everyday habits and interactions with their surroundings. Observing the client's space can help them better understand their needs and create tailored treatment plans that might be more difficult to develop in a regular office setting if the client doesn't discuss the information. 

When to consider in-home therapy

In-home therapy might be a valuable option for those who can't attend regular office sessions due to physical limitations, lack of transportation, or responsibilities at home. It can also benefit people who are uncomfortable seeking treatment in an unfamiliar office setting or want to receive treatment from the comfort of their home without visiting crowded waiting rooms at mental health facilities.

In-home therapy is frequently utilized by child welfare agencies, community support organizations, and those serving individuals with disabilities. In addition, some insurance plans may cover in-home mental health services when medically necessary. 

Who is in-home therapy for?

Home-based therapy programs can be used by people of various ages with different challenges. Regardless of your background, you may consider this option. However, the following groups may benefit the most from in-home treatment options.  

Older individuals

In-home therapy may be helpful for older adults with mobility challenges or chronic pain, which may make it difficult to attend regular therapy sessions at a clinic. By offering services in the comfort of their homes, in-home therapists can better meet the needs of this age group. However, you do not need to have an illness to request home services for an older family member or yourself. Insurance may not cover in-home counseling services, but if you have a mental health diagnosis, it may not be necessary for your to have a health care condition for home-based therapy. 

Individuals with disabilities

Some individuals with disabilities may also find in-home therapy more suitable due to physical or cognitive disabilities that make traveling challenging. Some disabled individuals may benefit from customized support and care, which in-home therapy professionals can often provide in a familiar setting.

Postpartum parents

Some new parents may experience challenges like postpartum depression as they adjust to the physical, emotional, and psychological changes that follow childbirth or adoption. With in-home therapy sessions, new parents can have a comfortable space to work through any difficult emotions they may be dealing with while still being able to care for their children. 

Individuals with agoraphobia or severe social anxiety

People with agoraphobia or  severe social anxiety  may struggle to leave home or go to an unfamiliar office for therapy sessions. Receiving therapy at home may be easier and more comfortable for clients. Intensive in-home counseling services can offer therapy in a safe environment while clients work through their mental health care treatment plan. 

Individuals with a substance use disorder

Therapists can provide tailored support through in-home services for individuals with a substance use disorder. Delivering therapy in the individual's home may also help the therapist create a more effective coping plan. As the client can remain in their own space, the therapist can help them eliminate items that might incite the urge to use substances. 

If you are struggling with substance use, contact the  SAMHSA National Helpline  at (800) 662-4357 to receive support and resources. 

Types of in-home mental health therapy

Different types of mental health services and counseling can be applied through in-home services. Mental health professionals, like psychologists, counselors, and social workers, can come to your house to provide support, whether you’re seeking individual, couples, or family therapy. Below are some of the most common services that may be offered. 

Home-based counseling

In-home counseling involves a mental health professional coming to your home to discuss stress, anxiety, communication challenges, or other mental health topics. The counselor may be a psychologist, social worker, or other qualified professional with special training in home-based counseling. 

Couples home-based therapy

A therapist can come to your home to help you and your partner work on your relationship with couples therapy. The therapist can be a marriage and family therapist or another mental health professional. In-home couples therapy may be helpful because it's in a familiar space, making it easier for some people to discuss personal topics. It can also remove the stigma that some couples may feel in going to a therapist's office, allowing a therapist to see how you and your partner interact in your home or with your children. 

Family therapy

In-home family therapy involves a family therapist working with family members directly from home. A family therapist can help family members work through conflicts and  improve relationships . The therapist can observe the family dynamic at its source, allowing them to offer more tailored advice. 

Individual therapy

Individual at-home therapy focuses on supporting those with mental health conditions like anxiety or depression in their homes. Different mental health professionals may offer this support. If mental illness is causing difficulty leaving home or setting appointments, a therapist can guide clients in coping with these challenges in a space that is theirs. 

In-home vs. online mental health services

In-home and online therapy allow people to receive help without leaving their homes. However, with in-home therapy, a mental health professional comes to a client's home and delivers therapy physically. With online therapy, a client connects with a mental health professional virtually and has therapy remotely wherever they have the internet, such as from home. 

People may prefer different approaches, and there may be situations when one approach works better. For instance, home-based therapy may be more effective for people who want to have therapy at home but don't have a reliable internet connection or are uncomfortable using technology. Contrarily, some clients may enjoy the convenience of having therapy at home but are uncomfortable having a therapist visit them in their space. In these cases, online therapy through platforms like  BetterHelp  may be more convenient, as they allow clients a level of distance from the provider. 

One example of this dynamic could be an individual with depression, who may be exhausted and experience low energy. Their depression symptoms may make it difficult to leave the house, do household chores, and maintain personal hygiene, which could make them wary of hosting someone in their own space. In this situation, online therapy could be beneficial. In addition, research has demonstrated the effectiveness of online therapy, with some studies showing it can be  as effective as in-person therapy  for conditions like major depressive disorder. 

In-home therapy can address barriers like transportation and childcare concerns that might prevent clients from seeking therapy in office settings. Online therapy can also be considered for individuals seeking help from the comfort of home without having a therapist enter their house.

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Counseling today , knowledge share, creating successful home visits in community-based counseling.

By Robin M. DuFresne and Allison K. Arnekrans March 9, 2020

Home-based counseling, which is sometimes referred to as community-based counseling, can be effective and beneficial with multiple client populations, including families, older adults, children, and individuals with developmental disabilities. Mood disorders, anxiety disorders, psychotic disorders, behavior problems and family disturbances are typical presenting problems that may benefit from home-based counseling. It is often helpful to have a counselor in the home environment to witness maladaptive behaviors, relational issues and other contextual considerations. Finally, home-based counseling can be particularly helpful for individuals who cannot or will not come to a counselor’s office for services.

Transferability of skills is one main benefit of home-based counseling, meaning that it can be helpful to those who struggle to transfer skills from one environment to another environment. For example, a child with intellectual disabilities and behavior problems may be able to successfully implement a calming technique in the counselor’s office but unable to do the same thing in the home. Learning and practicing the skill in the home environment with the counselor present to assist and support the child increases the likelihood of success. Additionally, the counselor can observe the parent or caregiver prompting the child to use the skill and work with them to increase consistent implementation. Another example is that of adults diagnosed with anxiety who struggle to use effective coping skills in triggering situations. In the home, the counselor can prompt the individual to recognize the triggers before anxiety begins and encourage the use of coping skills.

Home-based counseling offers the counselor a more enriched perspective of the client and the context of the presenting issues. Issues specific to the family or environment can be assessed through examples and observation in the here and now, which often leads to a more immediate feedback process. For example, family members may be on their “best behavior” while in the counselor’s office, or an individual family member may deny their part in a problem. Conducting counseling in the home allows the counselor to directly observe these behaviors and use immediacy to point them out, then work collaboratively to identify more appropriate behaviors.

In combination with behavioral indicators, the physical environment and the home’s level of cleanliness can provide the counselor with important information relative to the client’s situation. For example, a client who cannot pay her rent, has little food available for her family, and has broken floorboards in the kitchen may not have the same focus or motivation as a client in a more stable living situation.

Finally, clients may “no-show” or cancel office-based counseling sessions for a variety of reasons. Examples include the recent loss of transportation or employment, parental leave for a new baby, medical or health issues that warrant bed rest, severe and limiting psychiatric symptoms and so on. Home-based counseling provides the opportunity to meet clients where they are and with what they can contribute to the relationship.

For instance, clients diagnosed with a psychotic disorder may experience symptoms such as paranoia that prevent them from coming to the office and seeking treatment or engaging in other activities such as grocery shopping. A home-based counselor could work with such an individual in their home to help them identify their feeling of paranoia and learn to use reality-testing techniques to decrease the paranoia.

Although home-based counseling offers many benefits, ethical and safety concerns can dissuade professional counselors from providing this service. Additionally, the possibility of experiencing counselor burnout is a factor to consider when evaluating this type of format for sessions.

Ethical concerns

Counselors are required to act ethically when providing counseling services to their clients. Confidentiality, boundary issues and access to supervision are among the ethical concerns that counselors are likely to encounter when providing home-based counseling services.

Confidentiality

One of the primary ethical duties of counselors is to maintain their clients’ confidentiality. However, confidentiality is difficult to guarantee or provide in home-based settings, where the structure and consistency of the office-based setting are not in place. When entering a client’s home, the counselor cannot be certain who else might be residing in or visiting the home during the session. A roommate could walk through the front door, or a sibling might refuse to leave the common space — either of which could jeopardize the progress and process of counseling. Additionally, if multiple people are participating in the session, confidentiality cannot be guaranteed. Maintaining confidentiality can be particularly difficult if the home is small or if it lacks sufficient and safe space to conduct a private session.

When counseling children and families, confidentiality requirements change. Children do not own the right to their own confidentiality; this belongs to the parent or guardian. Counselors explain to both the parents and the child the limits of confidentiality. In the office, the counselor can suggest that the parent wait in the waiting room while the session is occurring, affording the child the feeling of privacy or confidentiality. In a home setting, it may be more difficult to persuade the parent that they should leave the room during the session. The parent may insist that because the counselor is in their home, the parent has the right to be wherever they want to be within the home. Communicating the importance of allowing the child to have some privacy can be more difficult in such situations.

Counselors are taught to respect the boundaries of the counseling relationship and to consider how bending those boundaries might affect the counseling relationship. Typically, counselors do not interact with their clients outside of counseling sessions. Establishing these boundaries is much easier when there is an office space dedicated specifically to counseling and when time constraints must be observed (e.g., staying on task with a session because the next client has already shown up for their appointment). Once in a client’s home, however, boundaries can become blurry. Both the client and the counselor might struggle with boundaries of time and space.

There are a few ways that clients may blur the boundaries in their homes that are different from what is typically experienced in an office setting. For example, the client may feel inclined to provide food and drink as if they were entertaining a guest. This puts the counselor in the position of deciding whether to accept and what messages this decision may send. Accepting can set a precedent that the client needs to “entertain” at each session. The client may also feel that they have to clean their home or otherwise change their environment to impress the counselor. If the client is putting on a show, this may interfere with the authenticity of the counseling relationship.

Counselors may blur the boundaries by becoming so comfortable in the client’s home that they begin treating the counseling relationship as a friendship or become distracted by the environment. It can be easy in a relaxed setting to spend too much time checking in and lapsing into chitchat rather than focusing on doing the needed work on client issues. This can be particularly true if the location of the counseling in the home changes from session to session.

Supervision

Most counselors are required to undergo weekly supervision while accruing hours toward their license to practice independently. Access to this supervisor can be difficult, however, when counselors are not down the hall from or in the same building as their supervisor. This circumstance may tempt counselors to make decisions without seeking supervision or consulting on important issues when they should.

For example, a counselor might assess a client for suicidal ideation but be unsure about the results. Rather than contacting the supervisor, the counselor may decide to trust their own judgment. This could lead to a wrong assessment and intervention plan. It can also be difficult for the supervisor to monitor the services being provided or to evaluate the supervisee when the supervisee is not based at the same location. The feedback process is altered merely by proximity and immediacy in the home-based environment. This can have ethical implications that are different from those in the office setting.

Safety concerns

In addition to ethical concerns, client and counselor safety should be considered. A client’s home can be an unpredictable environment with safety concerns for the counselor. These can include safety concerns related to pets, physical barriers, the client’s neighborhood, other people associated with the client, and so on. For example, the counselor may be allergic to the client’s pets, or a pet might not be happy about having a stranger in the home and become aggressive. Conversely, the pet may be overly friendly. If the counselor is not comfortable with the pet’s behavior, the pet could misread the counselor’s actions and become aggressive. These interactions with the pet might make it untenable for the counselor to continue providing home-based services to the client.

Counselors also need to be aware of people in the household who could pose a safety concern. One example is when a client’s significant other is unhappy about the client seeking help. The significant other may become intimidating or aggressive toward the counselor to prevent the client from receiving services.

Clients themselves could be a threat to the counselor. If the client has a history of aggressive behavior, the counselor may want to consider seeing the client in an office or referring the client to an office-based counselor.

Counselors may also struggle with concerns over client safety. For example, a client could be expressing homicidal or suicidal ideation. Even though the client is not threatening the counselor, intervention may be needed to protect the client or others. Under such circumstances, a newer counselor may need to seek immediate supervision or a more experienced counselor to help them access more intensive interventions. If the counselor does not have direct access to their supervisor, they may not be able to intervene appropriately. At the agencies where we worked, we were encouraged to have contact information for our supervisors and an experienced counselor easily accessible in our cell phones and computers.

Being mindful of ethical concerns and safety concerns while trying to assist clients in making positive changes can lead to stress and burnout for home-based counselors. American psychologist Herbert Freudenberger first coined the term burnout in the 1970s as a way to describe the consequences of severe stress associated with the helping professions.

Burnout has three components: 1) loss of empathy, 2) a decreased sense of accomplishment and 3) feelings of emotional exhaustion. Common experiences of burnout can include sleep disturbances, blurred boundaries, feelings of relief when a client is late or cancels, and even realizations that one is not paying attention when the client is speaking. It is not uncommon for professional counselors to experience burnout at some point in their careers, but home-based counselors often experience these negative symptoms more frequently than do their office-based peers. Three possible reasons for this phenomenon are the physical demands of travel, the toll of consistently facing difficult client issues, and the realities of operating in professional isolation.

First, home-based counselors are moving around all day. The sense of being established and organized flies out the window when one’s trunk is filled with therapeutic toys and the filing system for client worksheets has toppled over in the back seat of the car. Home-based counselors bring their entire office on the road. This can present challenges in terms of the utilization of space, one’s level of organization, and how one’s work life impedes on one’s personal life — especially for counselors who must use their own cars on the job.

In addition to these challenges, home-based counselors must face off against weather conditions and the general wear and tear of travel. Traffic, construction, road hazards and car issues present ongoing and uncontrollable stressors for counselors working in the field. A colleague comes to mind who hated to travel on the weekends for her son’s soccer games because she was so frustrated by having to drive all week for work. She became exhausted by the physical demands of lugging her laptop and resources around and dispirited by having to repeatedly pay for car repairs. These external sources of stress piled up and finally led her to look for another position. Although the travel involved in a home-based position might provide counselors with variety, flexibility and stimulation, too much of any one of those things can lead to burnout.

Home-based counselors can also be affected by burnout as a result of encountering more intense client issues in the field. In general, home-based clients are seeking services due to a lack of resources, systemic issues, family/relational issues or co-occurring diagnoses. These cases tend to be more laborious, time consuming and complex than are cases for the average office-based client. This might be because of the amount of phone calls, interdisciplinary meetings, paperwork, crisis management and case management involved in the wraparound approach.

In addition, because home-based counselors travel from site to site throughout their workdays, they do not necessarily receive the downtime to process, reflect, or consult with other counselors and supervisors who could offer a supportive ear. As a result, compassion fatigue may set in and result in counselor burnout.

Additionally, home-based counselors often lack the structure of a set schedule. They may need to finish documentation at home or after hours depending on how the day went. The likelihood of burnout increases when boundaries are blurred, time “on” and time “off” are not distinct, and there is little to no time to process client issues.

Finally, the daily work of home-based counselors can be perceived as isolating or lonely. Although there is interaction and stimulation with many other people throughout the day, home-based counselors often lack professional support and the ability to vent and collaborate with colleagues after sessions. There is also less time for immediate supervision and consultation on client issues, mainly due to having to pack up and get to the next home. Details are lost, and there is less time for the home-based counselor to process and conceptualize, all of which invite burnout more quickly than normal.

Tips for success

At this point, we know that the work of home-based counselors can be physically and emotionally challenging, although it can also be very rewarding and client-centered. To mitigate against the effects of burnout, several tips and strategies can be implemented to more fully wrap around these counselors, increase employee satisfaction and improve client outcomes.

To address the physical demands of the position, home-based counselors should carefully consider their schedules and level of organization. Taking time each week to plan, pack, and create structure for themselves can be invaluable. For example, instead of driving from ZIP code to ZIP code, counselors should, if possible, map out their schedules based on mileage or on seeing all clients from one area on a specific day. Meetings and supervision can be planned for a day of the week that coincides with time for completing paperwork in the office, when the counselor will have access to a printer and other resources. “Work smarter, not harder” was a popular catchphrase in our agencies when we were providing home-based counseling services.

Additionally, supervisors should have access to and be mindful of home-based counselors’ caseloads and schedules. Travel time, weather conditions and the possibility of a session getting extended due to crisis should all be considered each day. On particularly hot days, Allison’s supervisor would have popsicles and cold bottled water available at the weekly team meetings. This was a small gesture, but it made the counselors feel cared for given the unique demands of their job.

In terms of addressing safety challenges, home-based counselors should remain prepared, observant and cautious of their surroundings. One way to prepare is to have the first meeting with the client in an office setting. The counselor can use this initial meeting to assess whether the client is an appropriate fit for home-based services. If the client shares that they have a significant other or a pet who has been aggressive in the past, for example, then the counselor might decide to refer to office-based counseling. If the client reveals having a pet that the counselor is allergic to, the counselor can refer to a different home-based counselor who is not allergic. Setting a starting and ending time for the home-based services is also advised.

Once in the community, safety precautions could include keeping a basic food and hygiene kit in the car in case of an emergency. Carrying proper identification, making sure one’s phone is charged, and wearing appropriate clothing and footwear are easy steps to take to retain some level of control. It is sometimes advisable to avoid certain roads or areas to reduce the risk of injury or crime. Counselors can position themselves near the door of the house or apartment if they fear that their client or someone else in the home could become aggressive. Counselors may also want to be aware of items that agitated clients or others in the home could use as weapons. Rather than meeting the client in a home environment that the counselor fears could be unsafe, the counselor might encourage the client to meet at a community center or somewhere else that is less isolated. In addition, there are benefits to learning about the resources available in the client’s community and networking with other local agencies concerning opportunities and supports.

The use of a team-based approach is one method for increasing support for home-based counselors while simultaneously decreasing the feelings of loneliness that they sometimes experience. Weekly team meetings at rotating locations, group text messaging, daily “counselor check-ins” by email or phone, quarterly retreats, and staff recognition/celebrations are other examples of intentional ways that supervisors can create a layer of protection and support for their home-based counselors. A team-based approach can also help to process any of the ethical concerns that may arise when counselors are in the field.

Finally, personal wellness and a SMART-based (specific, measurable, achievable, realistic/relevant, time-limited) self-care plan are essential to the success and sustainability of home-based counselors. Intentionally planning one’s schedule to include time for paperwork and continuing education is important to reduce the amount of work that flows over into time off the clock.

As much as possible, home-based counselors should provide distinction between their work selves and their nonwork selves — not only for themselves but for their colleagues and loved ones as well. For example, one of this article’s authors would use the ride home from her last session to mentally process the day so that she could “leave” her work in the car. Staying physically active and making room for rest are important too. Home-based counselors should also be sure to stay engaged with others through consultation, supervision and collaborative efforts. Engaging in personal counseling as a form of self-awareness and health maintenance can be helpful as well.

Home-based counseling can be a daunting experience for novice counselors, but it can also be a rewarding and enriching experience, both for them and their clients. Properly assessing clients and ensuring appropriateness for home-based visits is the first step toward a productive working relationship. Understanding the various aspects of the position, including ways to be strategic and maintain appropriate boundaries, is also essential for the home-based counselor. Likewise, it is important to implement regular ethical and safety checks, in addition to scheduling sufficient time for paperwork, supervision and collaboration each week. Each of these strategies can help counselors be successful out in the field, even with some of the most difficult client issues. Those who supervise home-based counselors should focus on using a team-based approach to help prevent isolation and burnout in these counselors.

At the end of the day, home-based counseling is challenging work, although it is also meaningful and often quite productive. We encourage you to think about it as a possibility when looking for your next job.

Robin M. DuFresne is an assistant teaching professor and program coordinator for the clinical mental health and school counseling programs at Bowling Green State University in Ohio. She has worked in a variety of settings in community mental health. Contact her at [email protected] .

Allison K. Arnekrans is an associate professor, faculty adviser for the Mu Kappa chapter of Chi Sigma Iota, and practicum and internship coordinator at Central Michigan University. She is a child and adolescent counselor by trade, with experience in community mental health, partial hospitalization and employee assistance program settings. Contact her at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Letters to the editor: [email protected]

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How do I get a copy of Creating Successful Home Visits in Community-based Counseling By Robin M. DuFresne and Allison K. ArnekransMarch 9, 2020

ACA members can access all past Counseling Today issues at https://www.counseling.org/publications/counseling-today/archive . This article is featured in the March 2020 issue. If you would like to purchase a print copy of this issue (for $15), please call ACA in-house fulfillment at 800-298-2276 or email us at [email protected] .

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In-Home Counseling for Patients, Families and Caregivers

HCCInsights: Would you provide some background on In-Home Counseling, including types of services provided, who your patients are and the geographic areas you cover?

Reinwald: In-Home Counseling provides short- and long-term psychotherapy and counseling in the home, and over the phone, and via telehealth. We specialize in treating the geriatric population and those who have barriers or limitations to leaving their homes, though we also can see clients as young as 11 years old.

Patients are typically referred to us through medical or mental health professionals for concerns such as anxiety, adjusting to new living arrangements, aging issues, new or worsening medical issues, isolation, grief and loss, caregiver stress, phobias, mental illness, and the emotional impact of physical conditions.

In-Home Counseling was started in 2008 for a single client by a social worker. She then offered in-home visits to older adults because she saw a need. Soon, through word-of-mouth, she began being asked to see patients by medical and mental health professionals across the Chicagoland area. At that point, she hired more social workers to assist, many of whom still work for In-Home Counseling.

We started accepting insurance in 2009 and then began receiving referrals from more medical professionals across Chicagoland and Rockford, Lake County, McHenry County, DuPage County, and Will County. We now have more than 100 counselors across Chicagoland and have expanded into nine states, including Michigan, Wisconsin, Arkansas, Colorado, Texas, Tennessee, Florida, Indiana, and California.

HCCInsights: Besides home-based primary care providers, who else refers clients to In-Home Counseling?

Reinwald: Most of our referrals come directly from medical or mental health professionals. We receive referrals from home health agencies, specialty doctor groups, dialysis clinics, hospice organizations, caregiver companies, oncology and other specialty practices, hospitals, and insurance companies, among others. At times we are also called into assisted living facilities where we may have a counselor see multiple patients. Plus, clients and caregivers themselves can also reach out directly to us.

HCCInsights: Are the counseling services provided by In-Home Counseling covered by insurance?

Reinwald: Yes, we accept Medicare, Medicaid, most Medicare and Medicaid commercial replacement plans, and most commercial insurances across all states. Of course, insurance plans vary, but if an elderly patient, for example, has Medicare and does not have any supplemental insurance, or does not have Medicaid, it would be 20% for the co-insurance amount. If they do have Medicaid or a supplemental insurance, there is typically no cost per visit.

HCCInsights: Do the counselors work directly for In-Home Counseling?

Reinwald: All the counselors in our network work for In-Home Counseling. We do the interviewing, background checks, and all credentialing. The counselors also receive ongoing education, training, and support from our clinical and management team.

HCCInsights: What are the main types of situations your counselors get involved in? Reinwald: We provide psychotherapy (i.e., talk therapy) in the home, or by phone or telehealth, for those who are feeling depressed, anxious, stressed, having family issues or other adjustment issues, and more. The issues may be limiting an individual’s ability to live a full happy life. In addition to providing mental health counseling, counselors also connect patients to additional resources such as other medical professionals, Meals on Wheels, and so on.

HCCInsights : How would a home-based primary care provider assess whether in-home counseling is appropriate for their patient and refer a patient to you? Reinwald: The provider can call In-Home Counseling’s intake team at 888-903-5604 for help with determining whether in-home counseling would be appropriate or to make their referral over the phone. Often, the provider has already done a depression screen and knows the client has some significant depression or other mental health issues – or the provider has observed the client is tearful, isolated, anxious, or having compliance issues with their medical treatment.

The provider can also initiate a referral by faxing 224-788-5112. We also have referral forms we can email to the provider and can accept referrals online at www.InHomeCounselingServices.com (click on the “Referrals” tab).

Once we have the referral information, In-Home Counseling verifies the insurance eligibility and then we identify a counselor who would be the best fit for that client. We reach out to the counselor who in turn contacts the client to schedule an appointment at a time that works well for both. Scheduling is flexible and worked out between the counselor and client. If we run into any scheduling difficulties or can’t reach the client, we reach back to the referring provider to let them know.

HCCInsights: What role does the primary care provider play in the counseling process? Do they have an initial consultation with the counselor and then receive updates?

Reinwald: When a patient is referred for services, we ask the referring provider/source for information about the patient so that we can match the patient’s needs with a counselor. In terms of sending the provider updates, the patient will first need to agree with our doing so by signing a release form. Then we can send the provider treatment notes on a regular basis by email or fax, or the counselor and provider may speak by phone.

In-Home Counseling can also provide visit reports to physician groups that would like to partner with us. These reports include patient visit dates and case statuses and are sent on a semi-monthly or monthly basis, depending on the group’s preference.

HCCInsights: What process does a counselor follow with the patient for treatment?

Reinwald: Counselors begin an assessment at the first visit. This is where they learn about the client’s life and health history, complete a mental health screening, and evaluate the client’s emotional health to determine treatment direction and diagnosis. They also begin creating a treatment plan for the client to follow.

The client’s needs determine the duration and frequency of visits. Typically, most visits are 60 minutes, once per week, to start. The duration of treatment may be a couple of months or it can last longer if there are chronic mental health concerns. Our goal is to help improve the client’s mental health and maintain or improve their current level of functioning, depending on the case.

HCCInsights: How has the pandemic affected the way services are being delivered? Have clients adapted to these newer ways of conducting visits?

Reinwald: Services are currently being provided face-to-face with providers following all protective guidelines — they wear masks, use hand sanitizer, and switch appointments to telehealth if they or the client are not feeling well. Services are also provided via telehealth and phone, dependent upon patient and counselor preference. We began using telehealth in March 2020, which allowed us to seamlessly continue offering services to existing clients and offer support to new clients. Post-pandemic, we will still have telehealth visits with all insurances that continue to allow its use.

As the pandemic has unfolded, we have seen more clients feeling isolated and depressed. Some who were being seen in person were transitioned to telehealth, which was initially challenging, but then it went well, which has helped the situation.

HCCInsights: How has COVID affected your clients’ well-being in general?

Reinwald: With some who were clients prior to COVID, session and treatment plans have changed to different degrees. They may feel more isolated because family members are not coming around as much. Some patients are also feeling more grief and loss. The increased loss of freedom brought about by the pandemic is significantly affecting the older adult community. Fortunately, the counselor’s visit, whether through telehealth or in-person, can alleviate some of the loneliness and feelings of isolation.

With younger people, it is also difficult. We’re seeing feelings of isolation brought on by the increase in remote learning and more kids are also withdrawing from their families. In children, depression can look like someone being tearful, but generally it’s more like withdrawing, changes in eating habits and personal hygiene, and things like that.

HCCInsights: How do counselors work with significant others and family members, and non-family caregivers?

Reinwald: It really depends on the situation and circumstances. We can provide family counseling to benefit the identified patient, which can help the whole family better understand the patient’s needs and how to support them. We can also provide counseling for spouses and significant others. In addition, there are times when we identify that a family member or caregiver needs their own support and counseling. In these instances, we encourage them to become a client of In-Home Counseling as well. That is a separate arrangement due to privacy/HIPAA issues.

HCCInsights: Last question – what do you love about house calls, about providing in-home counseling services?

Reinwald: That’s easy. It gives our counselors a more transparent view of what’s really going on. They can see whether the house is tidy, if there’s food in the cupboard, maybe there are a lot of animals in the home or the atmosphere is chaotic, and so forth. The in-home counselor gets a more accurate view of the client’s life – one they wouldn’t get during an office visit.

Providing in-home services also allows counselors to observe family members, caregivers, and the surrounding support system. Plus, it helps counselors build rapport in a different way – they’re not clinicians in an office anymore, they’re individuals coming into someone’s home. They see the family photos on the wall and can make deeper connections.

All of this helps the counselor better assess and treat the patient, which hopefully improves their situation and that of family and other caregivers.

How to Contact In-Home Counseling:

Phone: 888-903-5604 Fax: 224-788-5112 www.InHomeCounselingServices.com

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Novelette Aldred Birmingham, B18

Experience and Specialisations Abuse, Bereavement, Cultural or Race Issues, Mental Health General, Personal Development, Relationship Counselling or Marriage Counselling, Self Esteem, Spirituality, Stress, Work Related Issues Therapeutic Approach Gestalt, Humanistic, Integrative, Person Centred Fees £50 (Concessions available)

Alexandra Bacon Matlock, DE4

Experience and Specialisations Anxiety, Depression, Health Related Issues, Mental Health General, Phobias, Relationship Counselling or Marriage Counselling, Self Esteem, Stress, Trauma, Work Related Issues Therapeutic Approach EFT (Emotional Freedom Techniques), Humanistic, NLP (Neurolinguistic Psychotherapy), Person Centred, Solution-Focused Brief Therapy Fees £40 – £50 (Concessions available)

Julia Bailey Hornchurch, RM11

Experience and Specialisations Abuse, Bereavement, Child Related Issues, General Counselling, Health Related Issues, Identity Development, Relationship Counselling or Marriage Counselling, Sexuality, Spirituality, Stress Therapeutic Approach Humanistic, Person Centred Fees £35. Reductions for income & student counsellors

Natasha Bee Chelmsford, CM2

Experience and Specialisations Anxiety, Depression, General Counselling, Health Related Issues, Identity Development, Obsessions, Phobias, Post-Traumatic Stress and PTSD, Spirituality, Stress Therapeutic Approach Integrative Fees £35 to £45. (Concessions available)

Paul Robert Beevor Uxbridge, UB9

Experience and Specialisations Abuse, Anxiety, Depression, Eating Disorders, Mental Health General, Obsessive-Compulsive Disorder (OCD), Relationship Counselling or Marriage Counselling, Self Esteem, Self Harm, Stress Therapeutic Approach Brief Therapy, Person Centred, Psychodynamic Fees £40.

Marguerita Bennett Cheltenham, GL52

Experience and Specialisations Abuse, Addiction and Substance Abuse, Bereavement, Depression, General Counselling, Relationship Counselling or Marriage Counselling, Stress, Work Related Issues Therapeutic Approach CBT (Cognitive Behavioural Therapy), Integrative, Person Centred, Solution-Focused Brief Therapy Fees £35 (Concessions available)

Martine Sarah Bliss Hythe, CT21

Experience and Specialisations Addiction and Substance Abuse, Anxiety, Bereavement, Cancer, Depression, Health Related Issues, Loss, Relationship Counselling or Marriage Counselling, Stress, Work Related Issues Therapeutic Approach CBT (Cognitive Behavioural Therapy), Integrative, Person Centred, Relational, TA (Transactional Analysis) Fees £35 (Concessions available)

Angie Bradley Wolverhampton, WV3

Experience and Specialisations Abuse, Addiction and Substance Abuse, Anger Management, Anxiety, Bereavement, Child Related Issues, Depression, Post-Traumatic Stress and PTSD, Relationship Counselling or Marriage Counselling, Work Related Issues Therapeutic Approach CBT (Cognitive Behavioural Therapy), Humanistic, Integrative, Person Centred, Psychodynamic Fees £35 to £60 Individuals (60 mins). £30 Students (60 mins). (Concessions available)

Carolyn Bridgen Epsom, KT19

Experience and Specialisations Abuse, Child Related Issues, Cultural or Race Issues, Disability, Loss, Mental Health General, Sexuality, Spirituality, Trauma Therapeutic Approach Art Therapy, Brief Therapy, Jungian, Person Centred, Psychodynamic Fees £45.00 (Concessions available)

Tracey Yvonne Bristow Orpington, BR6

Experience and Specialisations Bereavement, Child Related Issues, Disability, General Counselling, Loss, Pregnancy Related Issues, Relationship Counselling or Marriage Counselling, Self Esteem, Trauma, Women-Specific Issues Therapeutic Approach Integrative Fees £45 (Concessions available)

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The Bluetree Clinic

Home Visits

Posted on: 24th October 2016

Making our service accessible for all is something that here at The Blue Tree Clinic we find extremely important. Sometimes getting out of bed and leaving the house can be a little too much to cope with. Here at The Blue Tree Clinic we want to make your life easier which is why we have a home visit service. This means that our excellent team will come out to your home, at a time which suits you, and provide the same top quality care that you would receive within our clinic.

Doing home visits allows for everyone in society to be looked after the way they deserve. We understand that there are many reasons why you can’t come to the clinic; sometimes leaving the home is extremely anxiety provoking, sometimes people are immobile or have difficulty walking and sometimes we just feel unable to travel and here at The Blue Tree Clinic we are more than understanding of these difficulties which is why we have ensured that we provide high quality and friendly home visits.

We understand that sometimes you can be nervous about welcoming a clinician to your home but all our team are very understanding and non-judgemental. We will respect your environment and ensure that you are comfortable with us being there.

So what do you need to do next? The quickest and easiest way to contact us is by using our online contact form.

We will then have a quick chat with you and outline what your home visit will entail.

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Free services are available to help senior citizens who are homebound. Services can help homebound seniors manage mental health issues and cope with the challenges associated with aging, including isolation, difficulty accessing community services, depression, anxiety, family conflict, and other challenges. At times, people may face added challenges such as decreased cognitive functioning, or the inability to care for themselves, and/or more serious mental illness. The Senior In-Home Counseling program helps people deal with all of these challenges.

Services include:

• Comprehensive biopsychosocial assessments
• Short-term in-home individual and family counseling
• Psychiatric evaluations
• Competency assessments
• Medication prescribing and management
• Caregiver counseling
• Referral and linkage to community services and resources
• Continued treatment for those consumers in need of long-term services

Evidence-based practices, such as cognitive behavioral therapy, are utilized in this program to provide behavioral health services with a high rate of success. In-home services are provided by a core program staff member, who is dually licensed as a registered nurse (RN) and a licensed professional counselor (LPC).

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Substance Use and Depression in Home Visiting Clients: Home Visitor Perspectives on Addressing Clients' Needs

Sarah dauber.

The National Center on Addiction and Substance Abuse

Frances Ferayorni

Stony Brook University

Craig Henderson

Sam Houston State University

Aaron Hogue

Jessica nugent.

Prevent Child Abuse New Jersey

Jeannette Alcantara

The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) under the Affordable Care Act has significantly expanded evidence-based home visiting services for pregnant women and new mothers at risk for child maltreatment ( Health Resources and Services Administration, 2015 ). Home visiting (HV) is the most widely used child maltreatment prevention strategy across the country, and typical models provide high-risk parents with education about child development and effective parenting, as well as linkages to childcare, medical, and early intervention services ( Azzi-Lessing, 2013 ). In line with their primary goal of child maltreatment prevention, most HV programs target pregnant women and new mothers with significant behavioral health risks known to be associated with impaired parenting such as substance use and mental health problems. However, the HV workforce is comprised of a wide range of professional and educational backgrounds, with many programs staffed largely by paraprofessionals who lack the necessary clinical training and skills to address challenging behavioral health risks ( Paulsell, Del Grosso, & Supplee, 2014 ). While this discrepancy between client need and workforce qualification has long been recognized, the MIECHV legislation provided new impetus for action to address this mismatch by requiring state HV systems to demonstrate improvement on benchmark outcomes related specifically to maternal mental health ( U.S. Department of Health and Human Services, 2014 ). Consequently, initiatives to bolster HV capacity to address maternal behavioral health have begun to emerge within HV networks.

Much of the work to date in this area has focused on maternal depression (MD), and has included mandated depression screening within HV, providing mental health consultation to home visitors, and integrating mental health treatment into home visits ( Ammerman, Putnam, Teeters, & van Ginkel, 2014 ; Le, Perry, Mendelson, Tandon, & Munoz, 2015 ; Price, Gray, & Thacker, 2015 ; Rowan, Duckett, & Wang, 2015 ; Segre, O'Hara, Brock, & Taylor, 2012 ; Segre, Stasik, O'Hara, & Arndt, 2010 ; Tandon, Leis, Mendelson, Perry, & Kemp, 2014 ; Yonkers et al., 2009 ). In contrast, maternal substance use (SU) has received comparatively little attention within HV behavioral health initiatives, and is often an exclusion criterion from studies examining the impact of depression interventions (e.g., ( Ammerman et al., 2011 ; Segre et al., 2010 )). Maternal SU is a significant risk factor for child maltreatment ( Dubowitz et al., 2011 ), is often co-morbid with depression ( Connelly, Hazen, Baker-Ericzen, Landsverk, & McCue Horwitz, 2013 ), and is prevalent among pregnant and parenting women ( Substance Abuse and Mental Health Services Administration, 2014 ), the population served by HV programs. Expansion of existing behavioral health initiatives within HV to include SU is sorely needed. In order to inform the development of an enhancement to HV aimed at addressing both SU and MD, the current study presents the results of a survey that asked home visitors to report on their current practices, knowledge and perceived self-efficacy, perceived barriers, and training needs regarding SU and MD in their clients. This research emanates from one state network's interest in advancing its practice in addressing maternal behavioral health within HV, and is aligned with the national HV research priorities of supporting the development of a competent workforce and strengthening HV effectiveness ( Home Visiting Research Network, 2013 ).

Expanding HV capacity to address maternal SU in addition to depression is important for several reasons. First, SU is prevalent among mothers served by HV programs and is associated with increased risk for negative outcomes. According to the latest report from the MIECHV national evaluation, nearly 40% of HV clients reported binge drinking or using illegal drugs in the three months prior to program entry ( Michalopoulos et al., 2015 ). Maternal SU during pregnancy and in the early childhood years is associated with increased risk for child maltreatment as well as a host of negative child developmental outcomes ( Dubowitz et al., 2011 ; Institute of Medicine & National Research Council, 2014 ). Moreover, substance using mothers are at high risk for losing their children to the child protective system ( Berger, Slack, Waldfogel, & Bruch, 2010 ). Home visitors are present in the home during the critical early months, and, with proper training and support, have the potential to identify and address SU and associated problems early, prior to negative impacts on parenting and child outcomes. Second, the presence of client behavioral health risks such as SU has been associated with more difficult engagement in HV and attenuated program impacts ( Azzi-Lessing, 2013 ; Green, Tarte, Harrison, Nygren, & Sanders, 2014 ). Equipping home visitors with strategies to enhance engagement for high-risk substance using families as well as to assist them in accessing needed treatment could improve outcomes for these families.

Finally, the few studies that have directly assessed home visitor perceptions of their ability to manage client behavioral health risks have found that home visitors feel that they are lacking in important training and practical skills in this area. For example, one study found that home visitors' ability to recognize mental health and SU problems in their clients was generally below 50%, based on a comparison of home visitor records with positive screen data ( Duggan et al., 2004 ). Rates of referral for services were similarly low ( Duggan et al., 2007 ; Jones-Harden, Denmark, & Saul, 2010 ; Tandon, Parillo, Jenkins, & Duggan, 2005 ), with one study finding no service linkages for SU, and a linkage rate of only 2% for mental health ( Duggan et al., 2004 ). In a study asking home visitors to report on difficult situations encountered in HV, inability to connect families with needed mental health services and addressing SU were rated as among the most difficult ( LeCroy & Whitaker, 2005 ). Across studies, home visitors reported feeling generally ill-equipped to effectively address these issues with clients ( Eddy et al., 2008 ; Jones-Harden et al., 2010 ; LeCroy & Whitaker, 2005 ; Tandon et al., 2005 ), and required more training and supervision targeted specifically at addressing client behavioral health risks ( Tandon, Mercer, Saylor, & Duggan, 2008 ; Zeanah, Larrieu, Boris, & Nagle, 2006 ).

Beginning to Address the Need: Existing Behavioral Health Initiatives within HV

It has been suggested for more than a decade that HV programs shift their focus to more directly target maternal behavioral health risk factors for child maltreatment ( Chaffin, 2004 ; Duggan et al., 2004 ), and there is a growing body of literature documenting attempts to do so ( Ammerman et al., 2011 ; Boris et al., 2006 ; Chamberlain, 2008 ; Eddy et al., 2008 ; Gray & Price, 2014 ; Segre et al., 2010 ; Tandon et al., 2014 ). Nearly all of the attempts to date have focused on MD, and have included teaming paraprofessional home visitors with mental health consultants ( Boris et al., 2006 ), integrating evidence-based mental health interventions, such as cognitive behavioral therapy and interpersonal therapy, into home visits ( Ammerman et al., 2014 ; Gray & Price, 2014 ; Tandon et al., 2014 ), and training home visitors to implement brief behavioral health interventions ( Segre et al., 2010 ). Accumulating results from these initiatives have been largely positive, suggesting that enhancing HV with research-supported mental health interventions can be effective in reducing client symptoms of depression ( Ammerman et al., 2013 ; Segre, Brock, & O'Hara, 2015 ; Tandon et al., 2014 ). It is yet unknown whether similar impacts could be achieved by integrating interventions targeted at SU into HV programs.

To inform efforts to develop interventions targeting SU within HV, more systematic and comprehensive data are needed on the degree to which paraprofessional home visitors currently address SU in their clients that includes knowledge, current practices, training, and barriers to fully addressing client SU concerns. While several studies have surveyed home visitors on their perceived ability to address client behavioral health risks (e.g.,( Duggan et al., 2004 ; LeCroy & Whitaker, 2005 ; Tandon et al., 2008 ; Tandon et al., 2005 )), these studies have generally not focused on SU specifically as distinct from mental health. With a couple of notable exceptions ( Duggan et al., 2004 ; Tandon et al., 2005 ), studies conducted to date have grouped mental health and SU together into a single category of risk factors for child maltreatment. Additionally, these studies were all conducted prior to the MIECHV legislation and its accompanying emphasis on addressing maternal behavioral health, particularly depression, within HV. Finally, these studies did not assess barriers at both the system-level and client-level that may prevent home visitors from being able to adequately address behavioral health concerns in their clients. Potential systemic barriers that have been shown to prevent access to treatment among pregnant and parenting women include lack of available treatment options, long waiting lists, lack of transportation and childcare, and insurance or other payment difficulties ( Green, Rockhill, & Furrer, 2006 ; Rosen, Tolman, & Warner, 2004 ). Barriers at the client-level may include stigma, fear of losing custody of their children, fear of confidentiality violation, and prior negative experiences with treatment ( Abrams, Dornig, & Curran, 2009 ; Leis, Mendelson, Perry, & Tandon, 2011 ; O'Mahen & Flynn, 2008 ). The current study provides more recent data from home visitors in a single state who reported on their current practices regarding addressing SU and MD in their clients, including screening, referral for treatment, and assisting clients in overcoming common barriers to treatment attendance. Home visitors also reported on their knowledge, perceived self-efficacy, training, and barriers at both the system and client levels regarding addressing client SU and MD. Examination of potential differences in the extent to which home visitors address SU compared to MD across these distinct domains, as well as what may predict these differences, can help inform the development of strategies for supporting HV programs to better address client SU.

The study goals were (1) to compare the self-reported current practices of home visitors regarding SU and MD in their clients, and (2) to examine the degree to which differences in home visitor current practices regarding SU and MD can be explained by home visitor education, years of experience, prior training, self-reported knowledge of and perceived self-efficacy with the risk area, and home visitor perceptions of barriers at both the system and client levels. Given the recent national focus on enhancing HV to address MD, we hypothesized that home visitors would report more extensive management of MD compared to SU, as defined by their current practices. We also hypothesized that home visitor current practices in both risk areas would be predicted by more education, experience, and training, greater knowledge and perceived self-efficacy with the risk area, and lower perceived system-level and client-level barriers.

This study was reviewed by the governing Institutional Review Board (IRB) and was determined to be exempt from IRB oversight, as it reports on anonymous survey data.

Participants

Study participants included 159 home visitors from the Healthy Families America (HFA; N = 104) or Parents as Teachers (PAT; N = 54) programs in a single northeastern state. Both HFA and PAT are included in the MIECHV list of evidence-based HV models ( U.S. Department of Health and Human Services, 2014 ), and are widely implemented across the country ( Donelan-McCall, Eckenrode, & Olds, 2009 ; Harding, Galano, Martin, Huntington, & Schellenbach, 2007 ; Zigler, Pfannenstiel, & Seitz, 2008 ). Home visitors were recruited for participation in an anonymous survey at a mandatory state-wide HV networking meeting (October, 2013) hosted by the umbrella agency responsible for providing training and technical assistance to the state's HV programs. Survey participation was offered to all home visitors attending the meeting and 159 home visitors completed the survey on paper at the networking meeting, representing approximately 85% of the total number of HFA and PAT home visitors in the state at that time.

The study sample was 96% female, 20% White, 22% African American, 50% Latino/a, 3% Multiracial, and 4% of other racial/ethnic background. Education level of home visitors included high school or GED (12%), some college (33%), college graduate (42%), some post-college education (6%) or graduate degree (8%). Home visitors were 36 years old on average (SD = 11.9; Range 20 to 76 years), with an average of 4.25 years of experience as home visitors (SD = 4.30), and 3.25 years working for their current program (SD = 3.58).

Study Measure: Home Visitor Survey

Adaptation of home visitor survey. The survey used in this study is an adapted version of a survey developed in a prior study to assess the management of maternal depression among primary care physicians ( Leiferman, Dauber, Heisler, & Paulson, 2008 ; Leiferman, Dauber, Scott, Heisler, & Paulson, 2010 ). The conceptual model underlying the physician survey, grounded in the Health Belief and Social Ecological models, posited that the likelihood that physicians will address MD in their practice is impacted by their prior knowledge and training, level of self-efficacy (including confidence and comfort level with the topic), and barriers at the individual and system levels. The physician survey was administered to 217 primary care physicians and exploratory factor analysis was conducted, trimming items until adequate fit was achieved. The final structural model for the physician survey, described in Leiferman and colleagues ( Leiferman et al., 2010 ), demonstrated good fit: ( χ 2 (71) = 122.006, CFI = .959, TLI = .941, RMSEA = .058). Though the individual and system-level barriers scales were not retained in the final model for the physician survey due to lack of statistical significance in predicting physician practice, we felt it was important to include them in the current study analyses given the different service context being assessed (home visiting vs. primary care) and the importance of examining barriers for informing the design of interventions to address service gaps in the home visiting context.

The process of adapting the physician survey for the home visiting context included the following steps. First, we developed an initial draft of proposed adaptations based on a review of relevant literature, focus groups with home visitors, and discussions with HV program administrators. Second, the adapted item set was reviewed for content validity and accuracy by a panel of researchers, HV supervisors, and HV administrators. Finally, the item set was narrowed based on panel feedback. The majority of items on the final home visitor survey were identical to those on the original physician survey, with the following adaptations made. First, we extended the survey to evaluate SU as well as MD, using parallel items for both constructs. Second, the original physician survey assessed barriers via dichotomous check-boxes, and we converted these to Likert-scale items in the home visitor survey, a modification that was expected to improve the measure's psychometric properties. Third, we adapted the language of several of the barriers items to ensure we were assessing barriers relevant to the home visiting context (e.g., “Clients are afraid that they will lose custody of their children if they admit to feeling depressed/using substances”). Finally, we adapted the training items from the original survey to assess home visitors' training needs to inform intervention design.

The final home visitor survey consisted of 9 demographic items, 35 items on MD, and 36 items on SU 1 . With one exception, the survey contained parallel items for MD and SU to facilitate comparisons across the two risk domains. Survey respondents were asked to rate the extent of their agreement with a series of statements assessing their knowledge of each risk area, perceived self-efficacy addressing each risk area with clients, and perceived system- and client-level barriers to addressing risk with clients. Each of these items was rated on a 6-point Likert scale ranging from Strongly Disagree to Strongly Agree. Examination of item distributions revealed that most items had few scores at the most extreme ends of the scale. Therefore, prior to conducting factor analysis, the original 6-point response scale was recoded into a 4-point scale, collapsing the two agreement anchors (Strongly Agree and Agree) as well as the two disagreement anchors (Strongly Disagree and Disagree) in order to create more favorable distribution properties for analysis ( Nunnally & Bernstein, 1994 ). The final response scale was: 1=Disagree; 2=Somewhat Disagree; 3=Somewhat Agree; 4=Agree. Eight additional items per risk area assessed home visitors' current practices regarding the frequency with which they assess, screen, refer, follow up, and help clients overcome barriers to treatment for MD and SU. These items were rated on a 5-point Likert scale ranging from Always to Never.

Several additional survey items assessed home visitors' prior training and perceived need for future training in the areas of MD and SU. These items were not included in the Confirmatory Factor Analysis because only a single item assessing prior training was used in the predictive models; thus, there was no need to create a latent factor for training. The items on perceived need for future training are presented to provide additional descriptive information for intervention planning; these were not included in formal analyses. For each risk area, home visitors indicated whether they had ever received any of five types of formal training, including formal coursework, workshops, conferences, seminars, and web-based training. Training was operationalized as the number of types of formal training received for each risk domain (range 0-5). Finally, home visitors rated the extent of their agreement with three statements per risk area regarding their desire for more formal training, desire for standardized procedures for addressing MD and SU within home visiting, and willingness to implement standardized screening for each risk area. These items were rated on a 6-point Likert scale from Strongly Agree to Strongly Disagree. The hypothesized factor structure underlying the survey items is depicted in Figure 1 . Based on prior work with the physician survey ( Leiferman et al., 2010 ), we expected that survey items would cluster into four latent scales per risk domain: knowledge and self-efficacy, client-level barriers, system-level barriers, and current practices.

Hypothesized factor structure underlying the home visitor survey. MD = Maternal Depression; SU = Substance Use.

Confirmatory factor analysis

Confirmatory factor analysis (CFA) was conducted to confirm the hypothesized four-factor structure of the home visitor survey for the purpose of creating valid scales for analysis. Because we were able to construct a viable theoretical factor structure based on the results of the exploratory factor analysis (EFA) conducted on the physician survey ( Leiferman et al., 2010 ), we did not conduct an additional EFA on the home visitor survey. Due to power concerns, all analyses were conducted separately for MD and SU risk domains. CFA proceeded according to the following steps. First, we examined intercorrelations among all items expected to load on each hypothesized latent factor (see Figure 1 for the items expected to load on each factor). On several occasions, there were two items within the same proposed latent factor subscale that were highly correlated with one another. For example, within the proposed knowledge and self-efficacy scale, the item, “I feel confident in my ability to recognize MD/SU in my clients” was highly correlated with “I am familiar with the signs and symptoms of MD/SU” (MD: r = 0.52, p < 0.01; SU: r =0.71, p < 0.01) as well as with “I feel comfortable talking about MD/SU with clients” (MD: r = 0.44, p < 0.01; SU: r = 0.49, p < 0.01). In these instances, the item that was highly correlated with other items was excluded from further analyses. Second, a series of preliminary CFA models was conducted to determine whether the items corresponding to each latent factor adequately loaded on that factor. Poor performing items were trimmed as needed to achieve adequate fit for each model, with adequate fit defined as RMSEA values of .08 and below and CFI values of .90 and above ( Browne & Cudeck, 1993 ). Once adequate fitting models were established for each latent factor, final measurement models were fit for the MD and SU risk domains respectively.

The final CFA measurement models are depicted in Tables 1 (MD) and ​ and2 2 (SU). For MD, the initial full measurement model did not converge. To achieve model convergence, we freed the first factor loadings on each latent factor and fixed all factor variances to 1 ( Nunnally & Bernstein, 1994 ). The final MD measurement model demonstrated adequate fit: χ 2 (146) = 203.81, p < 0.01, CFI = 0.92, RMSEA = 0.05. For SU, the initial full measurement model converged with good fit: χ 2 (113) = 220.34, p < 0.001, CFI = 0.96, RMSEA = 0.08.

Note. χ 2 (146) = 203.81, p < 0.01; RMSEA = 0.05 (90% CI: 0.03, 0.07), p = 0.49; CFI = 0.92; TLI = 0.90.

Factor variances fixed at one.

Note. χ 2 (113) = 220.34, p < 0.01; RMSEA = 0.08 (90% CI: 0.06, 0.09), p < 0.01; CFI = 0.96; TLI = 0.95.

For both MD and SU, the final models included the following four factors: Knowledge and Self-Efficacy , System-Level Barriers, Client-Level Barriers , and Current Practices . The Knowledge and Self-Efficacy scale included 6 items for MD and 4 items for SU. For MD, factor loadings were below 0.40 for all items except for one (“I feel comfortable talking about depression with clients”), and Cronbach's alpha for the scale was very low (α = 0.05). For the SU Knowledge and Comfort scale, two items had factor loadings above 0.40, and Cronbach's alpha for the scale was 0.47. Despite low evidence of internal consistency for both MD and SU, this scale was retained for three main reasons. First, this scale demonstrated good fit in the preliminary CFA models for both MD ( χ 2 (9) = 8.91, p = 0.45, CFI = 1.00, RMSEA = 0.00; 90% CI: 0.00 – 0.09) and SU ( χ 2 (2) = 0.34, p = 0.85, CFI = 1.00, RMSEA = 0.00; 90% CI: 0.00 – 0.09). Second, despite the modest factor loadings in the final measurement models, inclusion of these scales did not detract from the overall good fit of the full measurement model for both MD and SU. Finally, knowledge and self-efficacy were important constructs in the conceptual model underlying the survey, and assessing the contribution of home visitor knowledge and self-efficacy to their current practices in order to inform intervention development was an important study goal, so the scales were retained on substantive grounds.

System-Level Barriers included 4 items each for MD and SU. For MD, factor loadings were at or above 0.65 for all items except one (“It generally takes a long time to get an appointment with a mental health professional”), and alpha was adequate at 0.50. For SU, all items had factor loadings above 0.40, with three out of the four items loading above 0.75. This scale showed good internal consistency for SU (α = 0.68). Client-Level Barriers included 5 items each for MD and SU. For MD, factor loadings ranged from 0.58 for “Clients feel bad about themselves when told they have depression,” and “Asking clients about depression would ruin the trusting relationship we have developed,” to 0.66 for “Clients often deny feeling depressed.” Factor loadings were somewhat lower for SU, however all but one item had loadings above 0.40 (“Clients feel bad about themselves when told they have a substance use problem”), and two items had loadings above 0.70. Internal consistency for the Client-Level Barriers scale was good for MD (α = 0.66) and adequate for SU (α = 0.52).

The final scale, Current Practices , included four items each for MD and SU. The three items in the original scale that measured specific ways home visitors helped clients overcome barriers to treatment (“How often do you help clients organize transportation”; “How often do you help clients organize payment”; “How often do you help clients arrange childcare”) were combined into a single item by averaging the scores on the three items in the original scale. This was done due to high levels of collinearity among these three items that was contributing to poor fit in the CFA. All items on the final Current Practices scale for MD and SU had factor loadings above 0.70, and internal consistency was very high for both MD (α = 0.84) and SU (α = 0.91).

Scale scores for each latent factor were calculated by averaging the scores for all items loading on the corresponding factor. The resulting scale scores for Current Practices , Knowledge and Self-Efficacy , System-Level Barriers , and Client-Level Barriers were then used as the independent and dependent variables in study analyses.

Data Analysis Plan

First, paired samples t -tests were conducted on the four survey subscales ( Current Practices, Knowledge and Self-Efficacy , System-Level Barriers , and Client-Level Barriers ) to examine differences between SU and MD. Next, predictors of home visitors' Current Practices were assessed via two linear regression models, one for SU and one for MD. Full models were conducted including all potential predictors (education, training, experience, Knowledge and Self-Efficacy , System-Level Barriers , and Client-Level Barriers ). Finally, descriptive statistics on home visitors' desire for additional formal training, desire for standardized procedures within home visiting, and willingness to implement standardized screening for the two risk areas are presented to inform the extent to which home visitors are open to training and practice enhancement in these areas.

Preliminary Descriptive Statistics

Descriptive statistics on all study variables are contained in Table 3 . As shown in the table, approximately half of the sample had graduated from college (55.3%), and about a third had more than five years of experience in HV, another third had between two and five years of experience, and 35% had less than one year of experience in HV. Home visitors reported receiving an average of about one type of formal training in MD or SU. Average scores on the Knowledge and Self-Efficacy scale were 3.03 (SD = 0.35) for MD and 2.84 (SD = 0.47) for SU, out of a possible range of 1 to 4, with higher scores representing greater knowledge and comfort. Regarding MD, average scores for System-Level Barriers (M = 3.34, SD = 0.57) were higher than those for Client-Level Barriers (M = 2.64, SD = 0.59). For SU, home visitors reported about the same level of System-Level Barriers (M = 3.05, SD = 0.72) and Client-Level Barriers (M = 3.19, SD = 0.44). For both barriers scales, possible scores ranged from 1 to 4, with higher scores representing more perceived barriers. The average score on MD Current Practices was 3.11 (SD = 1.00), which corresponds to “sometimes” on the response scale, and the average score on SU Current Practices was 2.37 (SD = 1.18), corresponding to “rarely” on the response scale.

Bivariate correlations among all potential predictor variables were examined to assess for multicollinearity prior to conducting regression analyses. Being a college graduate was significantly correlated with having less than one year of HV experience ( r = 0.45, p <0.01), and with less Knowledge and Self-Efficacy with SU ( r = -0.26, p < 0.01). Having more than five years of experience in HV was associated with having more formal training in both MD ( r = -0.20, p < 0.05) and SU ( r = -0.24, p < 0.01). More training in SU was associated with greater Knowledge and Self-Efficacy regarding SU ( r = 0.29, p < 0.01); however, this was not the case for MD. For MD, greater perceived Client-Level Barriers was associated with less Knowledge and Self-Efficacy ( r = -0.23, p < 0.01) and more System-Level Barriers ( r = 0.21, p < 0.01). For SU, greater perceived Client-Level Barriers was associated with fewer perceived System-Level Barriers ( r = -0.25, p < 0.01). All significant correlations were in the low to moderate range, and thus did not pose issues of multicollinearity for the regression analyses.

Comparison of MD and SU on Survey Subscales

Paired samples t -tests were conducted to compare home visitor scores on Current Practices, Knowledge and Self-Efficacy , System-Level Barriers , and Client-Level Barriers across the two risk domains (MD and SU). Significant differences between the two risk domains were found for Current Practices ( t (155) = 10.94, p < 0.001, d = 0.89), Knowledge and Self-Efficacy ( t (158) = 4.30, p < 0.001, d = 0.35), System-Level Barriers ( t (158) = 5.30, p < 0.001, d = 0.43), and Client-Level Barriers ( t (158) = -13.23, p < 0.001, d = 1.08). Means and standard deviations for each subscale by risk domain are presented in Table 3 . Scores on Current Practices, Knowledge and Self-Efficacy , and System-Level Barriers were significantly higher for MD compared to SU, and Client-Level Barriers were higher for SU compared to MD. Following the guidelines established by Cohen for the interpretation of effect size magnitude ( Cohen, 1988 ), effect sizes were large for Current Practices and Client-Level Barriers and small to moderate for Knowledge and Self-Efficacy and System-Level Barriers .

Potential Predictors of Home Visitor Current Practices in MD and SU

Linear regressions were conducted to examine potential predictors of home visitor Current Practices in managing MD and SU (see Table 4 ). A separate regression was conducted for each risk domain. Potential predictors included: college graduate (yes vs. no); up to one year experience in home visiting (vs. more than five years); two to five years of experience in home visiting (vs. more than five years); number of types of formal training received in MD or SU (range 0 to 5); Knowledge and Self-Efficacy scale score; System-Level Barriers scale score; and Client-Level Barriers scale score.

For MD, higher scores on the Current Practices scale were predicted by more types of formal depression training (B (SE) = 0.26 (0.08), p < 0.01, β = 0.27) and higher scores on the Knowledge and Self-Efficacy subscale (B (SE) = 0.55 (0.24), p < 0.05, β = 0.19). For SU, higher scores on the Current Practices scale were significantly predicted only by higher scores on the Knowledge and Self-Efficacy scale (B (SE) = 0.56 (0.21), p < 0.05, β = 0.22). Both training and experience predicted SU Current Practices at a trend-level, with more training (B (SE) = 0.17 (0.09), p = 0.07, β = 0.16) and more than five years of experience (compared to less than one year) (B (SE) = -0.48 (0.26), p = 0.07, β = -0.19) associated with higher scores on SU Current Practices .

Home Visitor Openness to Practice Enhancements Focused on MD and SU within HV

Home visitors reported on their desire for additional formal training, desire for standardized procedures within HV to address SU and MD, and willingness to use a standardized screening tool with their clients. These data are presented here descriptively to further inform intervention planning in this area. The vast majority of home visitors reported a desire for more formal training in MD (80.4%) and SU (84.6%). Additionally, more than 70% either agreed or strongly agreed with the statement “I wish there were standard procedures for dealing with MD/SU within HV” (71.4% for MD, 77.4% for SU). Finally, more than 80% expressed willingness to use a standardized screening tool to help them recognize MD (84.8%) or SU (83.3%) in HV clients.

This study presents results of a survey of home visitors within a single state who self-reported on their practices in managing (identifying and addressing) client SU and MD within the context of two widely used and empirically supported HV models. As expected given the current emphasis on MD under MIECHV, home visitors reported managing MD more extensively than SU. However, the extent to which home visitors reported currently managing both risk areas corresponded to approximately “rarely” or “sometimes” on the survey response scale. Thus, the degree to which home visitors currently identify and address both SU and MD in their clients is relatively low, by their own report. This finding is consistent with prior studies that found that paraprofessional home visitors infrequently identified and responded to behavioral health risks in their clients ( Duggan et al., 2004 ; Tandon et al., 2005 ).

Home visitors reported greater knowledge and perceived self-efficacy regarding MD compared to SU. Additionally, they perceived system-level barriers such as long waiting lists, insurance, and lack of transportation and childcare to be greater for MD compared to SU and client-level barriers, including client reluctance to discuss the problem and client fears related to child custody, to be greater for SU compared to MD. The past decade has seen increased recognition of the prevalence of depression among pregnant and postpartum women and the consequent risk posed to family functioning and child development ( Goodman et al., 2011 ; Paulson, Dauber, & Leiferman, 2006 ). As a result, early childhood intervention systems, including HV programs, have begun to institute policies regarding screening and referral to treatment for MD ( Horowitz, Murphy, Gregory, & Wojcik, 2009 ; Price & Masho, 2014 ; Rowan et al., 2015 ; Segre et al., 2012 ). Thus, home visitors may have had more training and more experience with MD compared to SU, increasing their perceived self-efficacy and decreasing their perception of client-level barriers such as stigma and fear of custody loss. It is possible that increased experience with the mental health treatment system due to the new focus on depression in HV heightened their awareness of systemic barriers to accessing treatment. However, further inquiry is needed to confirm these explanations.

Overall, few predictors of the extensiveness of home visitor management of SU and MD were found in the current study. Greater home visitor reported knowledge and self-efficacy with MD and SU predicted more extensive management of each risk domain respectively, and is consistent with other studies that have found that home visitors' personal comfort level discussing difficult topics impacts whether and how they address them with clients ( Rollans, Schmied, Kemp, & Meade, 2013 ). Additionally, more training was associated with more extensive management of both risk domains, though this was significant only for MD. Surprisingly, home visitor reported system- and client-level barriers did not predict current practices in either of the risk domains in this study. It is possible that factors that were not measured in this study may explain home visitors' practices regarding managing client behavioral health risks. For example, other studies have found that home visitor psychological characteristics, as well as characteristics of the home visitor-client relationship, are important predictors of home visitor behaviors in their work with high-risk families ( Jones-Harden et al., 2010 ). Specifically, home visitor self-reported anxiety has been shown to be associated with the likelihood of addressing sensitive topics with clients, with highly anxious home visitors less likely to address poor mental health in clients ( McFarlane et al., 2010 ). Home visitors may also experience burnout and secondary traumatic stress that often occurs in providers serving high-risk families and may detract from their ability to adequately address clients' needs ( Gill, Greenberg, Moon, & Margraf, 2007 ; Jones-Harden et al., 2010 ). While these variables were not measured in the current study, they will clearly be important to look at in future studies.

Prior studies have suggested that home visitors lack adequate training to address client behavioral health risks ( Duggan et al., 2004 ; LeCroy & Whitaker, 2005 ; Tandon et al., 2008 ). Our findings lend some support to this point, as home visitors with less training reported less extensive management of both MD and SU. However, more than 75% of home visitors in the study sample reported receiving at least one type of formal training in both risk domains, though the quality and intensity of training is not known. Home visitors in the current sample also reported high levels of confidence and perceived self-efficacy addressing both risk domains. Despite this, the majority of home visitors also reported a desire for additional training and for standardized procedures for addressing SU and MD with HV clients. Taken together, study findings largely support the need for interventions to enhance home visitor capacity to address SU and MD in their clients that would include enhanced training coupled with specific practice-based strategies targeted at client behavioral health.

Limitations

This study has several limitations that must be considered in interpreting the findings. First, the study sample was selective, including home visitors representing only two of the myriad HV program models as implemented in a single state, thus generalizability of findings is limited. Second, as indicated above, potential important predictive variables, such as home visitor psychological characteristics, were not measured in this study. Third, although the survey instrument used in this study was not a standardized validated tool, the constructed scales were based on a sound conceptual model used in a prior study ( Leiferman et al., 2010 ) and demonstrated good fit in confirmatory factor analysis. However, further psychometric evaluation would be needed to fully validate the survey as a measurement tool. Finally, all data were self-reported by home visitors and thus present only a single perspective on very complex issues. Recent qualitative research suggests that HV clients' views of their own depressive symptoms and their preferred way of receiving help differs from their home visitors' perceptions ( Price & Cohen-Filipic, 2013 ). Complementary surveys assessing client perspectives as well as perspectives of treatment providers, program supervisors and administrators, and other stakeholders would provide a more complete picture, particularly of the potential barriers to home visitor management of client behavioral health risks and client access to needed services. A larger-scale survey of home visitors, administrators, and clients that includes a larger sample, multiple perspectives on management of behavioral health risks within HV, and a larger spectrum of potential predictive variables is currently underway as part of the MIECHV-funded research program, and will provide further information to guide HV programs in addressing client behavioral health risks.

Implications and Future Directions

Study findings lend further support to several areas of need that have been increasingly stated by HV researchers and other stakeholders. First, HV programs must do more to support home visitors in identifying behavioral health risks such as SU and MD in their clients and promoting access to treatment ( Green et al., 2014 ; Paulsell et al., 2014 ). MIECHV legislation has already resulted in many local HV programs placing increased emphasis on maternal behavioral health risks ( Michalopoulos et al., 2015 ). In the recently released first report from the national HV evaluation, MIHOPE, more than 90% of HFA home visitors believed it was their responsibility to recognize and address mental health and SU in their clients ( Michalopoulos et al., 2015 ). However, about a quarter of home visitors felt that their programs did not provide them with adequate strategies and tools for addressing these issues and about 30% felt that they were not adequately trained in these areas. In the MIHOPE sample, many local programs reported having formal policies for screening clients for behavioral health needs, however only 20% had systematic protocols for how to respond to positive screens ( Michalopoulos et al., 2015 ). It is being increasingly recognized that home visitors are not routinely equipped with the requisite skills and tools to engage high-risk families, identify specific risk factors, and navigate complex systems to assist families in accessing needed services ( Azzi-Lessing, 2013 ). Second, HV researchers have suggested the need for more intensive and reflective supervision to provide essential support to home visitors in intervening with the highest risk families ( Azzi-Lessing, 2013 ; Jones-Harden et al., 2010 ). Qualitative studies of home visitor experiences suggest that the day-to-day of working with high-risk families takes an emotional toll, and adequate supervisory support as well as peer support is necessary to prevent burnout ( Dmytryshyn, Jack, Ballantyne, Wahoush, & MacMillan, 2015 ; Gill et al., 2007 ). Third, systematic consultation with service providers is a high priority, as formal collaborations with mental health and substance use providers are required to adequately meet the needs of high-risk families ( Jones-Harden et al., 2010 ). Because HV alone is not sufficient to adequately address the complex needs of vulnerable families, it must be viewed as one part of a larger, coordinated system of care that includes both child and adult services ( Azzi-Lessing, 2013 ).

As described in the Introduction, there have been several attempts to systematically integrate assessment and treatment for MD into HV programs. Results of these studies support the potential of integrating mental health interventions into HV for reducing client symptoms of depression. Whether or not similar approaches could work for SU is still an open question. Additionally, the approach of delivering behavioral health treatment directly in the home is costly and requires the availability of licensed mental health counselors, resources that are lacking in most statewide HV systems. A potential alternative is the integration of standardized behavioral health screening implemented by home visitors followed by brief intervention aimed at linking clients to needed services. This approach is based on the Screening Brief Intervention and Referral to Treatment (SBIRT) model that is widely used for SU problems in primary care settings ( Substance Abuse and Mental Health Services Administration, 2013 ), and has demonstrated notable success in improving access to treatment and reducing SU for adult substance users, though results are not definitive ( Agerwala & McCance-Katz, 2012 ; Babor et al., 2007 ). SBIRT has not been systematically attempted and evaluated within HV to date, however, arguably, this approach has potential as a way to address SU and mental health in the HV context. While SBIRT approaches may be more cost-effective than home-based treatment, they would rely on the skill of the home visitor to identify client risks, motivate the client to engage in treatment, and coordinate with service providers to eliminate barriers to treatment access. Additionally, the success of SBIRT is dependent on the availability and accessibility of quality community-based treatment services for home visitors to make referrals to ( Babor et al., 2007 ). To be effective within HV, such an approach must include behavior- and skills-based training for home visitors, collaborative partnerships with behavioral health providers, minimal additional burden, and adequate supervisory practical and emotional support for home visitors ( Azzi-Lessing, 2013 ; Dmytryshyn et al., 2015 ; Home Visiting Research Network, 2013 ; Jones-Harden et al., 2010 ; Tandon et al., 2008 ). The survey results presented in the current study were used to inform the development of a protocol to integrate standardized screening for SU, as well as for MD and domestic violence, into HV, followed by a brief intervention targeted at motivation and engagement of clients into needed services. A pilot feasibility test of this protocol is currently underway and results will be forthcoming.

Surveys such as the one used in the current study can be helpful in revealing service gaps and the particular barriers at play to inform the development of model enhancements and interventions to increase HV program capacity to address client behavioral health risks. However, additional research is needed that includes the perspectives of clients, administrators, and other stakeholders in addition to home visitors, to elucidate the individual, organizational, and systemic factors that determine how and to what extent maternal behavioral health risks are addressed within HV programs. Such research is being conducted as part of the ongoing national MIECHV-funded HV evaluation, and will be instrumental in informing the development of targeted strategies to expand HV program capacity to better meet the needs of the highest risk families while simultaneously supporting the practical and emotional needs of the HV workforce.

Acknowledgments

Preparation of this article was supported by grant 1R21DA034108 from the National Institute on Drug Abuse. Additional support for this project was provided by the New Jersey Department of Children and Families, the New Jersey Department of Human Services: Division of Family Development, and the New Jersey Department of Health. The authors gratefully acknowledge Anne K. Duggan, ScD, for her guidance in preparing this manuscript.

1 Note that the original survey also included 30 items on domestic violence that were parallel to the maternal depression and substance use items. However, survey validation analyses did not support the use of the domestic violence scales, so these items are not included in study analyses.

Contributor Information

Sarah Dauber, The National Center on Addiction and Substance Abuse.

Frances Ferayorni, Stony Brook University.

Craig Henderson, Sam Houston State University.

Aaron Hogue, The National Center on Addiction and Substance Abuse.

Jessica Nugent, Prevent Child Abuse New Jersey.

Jeannette Alcantara, Prevent Child Abuse New Jersey.

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Calls, home visits, counseling help get california students back to school, new data sheds light on chronic absences.

Betty Márquez Rosales , Lasherica Thornton , And Daniel J. Willis

April 9, 2024

When first grader Jordan Muñoz stopped going to school during the 2022-23 school year, his mother attributed it to depression, following the deaths of Muñoz’s great-grandfather and uncle. Some days, his mom couldn’t get him out of the house. Other days, she’d get him dressed and to the corner of Fresno’s Fremont Elementary, but he’d take off running. Most often, she failed to get him beyond the school parking lot.

“I tried to just take him. Leave him at school. But he would get right in front of my car so I wouldn’t leave,” said Muñoz’s mom, Deyanira Pacheco.

Aware of the difficulty, administration, counselors, psychologists and teachers at his Fresno Unified school developed a plan to support Muñoz, according to Cecilia Aguayo, the district’s child welfare and attendance specialist.

The district of over 70,000 students had made such plans before in an effort to reduce chronic absenteeism rates, which went from 50.3% during the 2021-22 school year to 35.4% in 2022-23. While this is still higher than pre-pandemic years, the decrease stands in sharp contrast to other districts, like Oakland Unified, where chronic absences rose from 47.5% to 61.4% during the same years.

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Statewide, nearly a quarter of K-12 students remained chronically absent during the 2022-23 school year — a decline of about 5 percentage points from the previous school year, but a sign of the lingering effects of the pandemic that led to sharp drops in student attendance after schools reopened for in-person instruction. Students who are chronically absent from school are sometimes also the same children who do not have their basic needs met: Federal data shows that nearly half of all California homeless students, 44.5%, were chronically absent during the 2021-22 school year.

Nearly a third of the 930 districts statewide that reported data had a higher rate of chronic absenteeism in 2022-23 than the year before. A small number of districts, 33, had a chronic absenteeism rate over 50% in 2022-23, the most recent data available.

EdSource’s analysis of data from the California Department of Education offers insight: The statewide average rate of excused absences for the 2022-23 school year was 54.7%, with unexcused absences at 39.2%. Both numbers are similar to pre-pandemic levels.

While both excused and unexcused absences are counted toward chronic absenteeism rates, a school’s knowledge of the reasons behind the absences can better help them support and re-engage students.

Researchers and school staff have long tried to better understand how to re-engage chronically absent students, or students who missed 10% or more days in one school year.

State education code lists over a dozen reasons for excusing students from school; however, interviews with districts show that many excused absences are mental health and illness-related. Unexcused absences could indicate that students did not have proper documentation to mark them excused, or that they provided no reason for their absence or that the reason they provided does not qualify as an excusable absence.

Fresno Unified is in the Central San Joaquin Valley and is the state’s third-largest district. Across the 30 districts in Fresno County, all but four decreased their chronic absences between 2021-22 and 2022-23. Altogether, the average change was 11.62 percentage points, with Fresno Unified, the county’s largest district, above average with a gain of 14.9 percentage points.

The district credits their targeted communication with families as the foundation for their improvement, a method echoed by researchers as highly effective .

Child welfare and attendance specialist Aguayo made phone calls, visited Muñoz’s home and popped up at the school when Pacheco picked up her other child, a kindergartner, who soon followed his brother’s example and sometimes refused to attend school. The district referred them to counseling services.

Although Pacheco, the kids’ mother, said the visits and calls helped in a way, she didn’t pursue counseling, perhaps thinking it wouldn’t work, Aguayo said.

By the end of the 2022-23 school year, Muñoz had attended only 27 days out of 179 days enrolled — a 15% attendance rate. Of the days missed, only six were excused. The school district didn’t give up on him, however. They used every tool to get him back to school.

Oakland Unified’s rising chronic absences

Farther north, in Oakland, chronic absences increased from 47.5% in the 2021-22 school year to 61.4% the following school year. But the high rate was already clear prior to the pandemic, at 34.4% during 2018-19.

“There hasn’t been a ‘normal’ year in many years,” said Heather Palin, the district’s director of multitiered systems of support, about chronic absences, in October. “Just broadly speaking, this is way higher than pre-Covid.”

Oakland Unified, located in the San Francisco Bay Area, is a diverse district of 46,000 students that is currently facing a significant budget deficit . Most districts across Alameda County, of which Oakland Unified is the largest, either saw a decrease in chronic absenteeism or had virtually no change between the 2021-22 and 2022-23 school years. Oakland Unified ranked last and stands out with an increase of 13.9 percentage points.

The district has adopted a plan aimed at reducing its 61.4% district absentee rate by 25 percentage points with similar drops in each individual school, Palin said.

Each Oakland Unified school is expected to have an attendance team that meets regularly and includes an administrator, community school manager, attendance specialist and principal. Teams’ plans for increasing attendance include offering incentives like attendance certificates, celebrations and swag.

“It was an expectation that was set last year, and we have more capacity to support it, and we’re more kind of unified as a system in the messaging around the importance of that team,” Palin said.

The district offers a virtual school, Sojourner Truth Virtual Academy , but it’s not aimed at students who are chronically absent. Rather, it’s a different learning format offered to all students.

Cumulative enrollment data shows that this school remained a popular choice for students: it had 250 enrolled students pre-pandemic, then jumped to 1,533 students during 2021-22. The following year, 2022-23, nearly 1,000 remained enrolled.

Palin said that district authorities do not know why all students are chronically absent because schools were unable to reach some families. The students they reached mostly said they no longer wanted to attend school or requested a transfer to the virtual academy. Students also cited illness, family relocation, mental health and safety concerns.

How insight from families can help

While school administrators can excuse absences based on students’ individual circumstances — even if the reason is typically not covered by state law — they can only do so if they know the difficulties absent students are experiencing.

According to a recently published PACE report that examined California attendance data across the 2017 and 2022 school years, schools with higher rates of unexcused absences often have lower attendance rates overall. The same study by the nonprofit research group found that “socioeconomically disadvantaged students are much more likely to have their absences labeled unexcused.”

To address the number of illness-related absences, Fresno Unified clarified expectations, informing families about appropriate scenarios in which to send their kids to school. Consequently, excused absences increased from 41.3% in 2021-22 to 54.8% the following year, while unexcused absences decreased from 64% to 43.4%.

When the district knows what’s impacting student attendance, they can support, not penalize families, which many feared, said Tashiana Aquino, executive director of support programs, and Abigail Arii, director of the district’s student support services.

The very few excused absences that Muñoz had, along with conversations with his mother, helped the district set up a plan to increase his attendance.

Staff sent letters, called, visited the home, and educated Pacheco about attendance laws. “They asked me why he didn’t want to stay at school,” Pacheco said.

But even with a plan in place, Pacheco couldn’t get Muñoz, 7, to school.

By Sept. 23, 2022, she’d enrolled Muñoz in the district’s eLearn Academy, hoping he’d complete the work from home. Still, he wouldn’t. Six weeks later, he was re-enrolled at Fremont but was still not attending school.

Pacheco faced a school attendance review board (SARB) case in June 2023, a step “we really tried to avoid,” Aguayo said.

But the case was the “wake-up call” that pushed Pacheco to get the help she and Muñoz needed, said district staff.

“I think that’s where she realized, ‘I need to step up, too,’” said Tainia Yeppez, the SARB technician.

During the case, Fresno Unified again referred the family to counseling services. This time, in summer 2023, Pacheco started Muñoz in therapy.

New, more flexible solutions

Ongoing chronic absenteeism requires new thinking, advocates say, to ensure students do not fall back on foundational academic skills.

“Just because kids are not in the school building doesn’t mean we can’t still figure out creative and innovative ways to educate them. These chronic absenteeism rates are not going to just drop,” said Lakisha Young , CEO and founder of parent advocacy group Oakland REACH. “Everybody is in uncharted territory. So the question is: ‘Can we change the conversation?’”

At the height of the pandemic, Oakland REACH established a virtual learning hub for Oakland Unified’s K-2 students, offering tutoring that kept them engaged and attending school regularly. Early results showed that 60% of their students improved two or more reading levels on the Oakland Unified assessment, while 30% improved three or more levels. The organization now offers paid fellowships for Oakland caregivers to work as tutors producing high academic results.

Part of the challenge with common alternative learning formats to re-engage absent students while meeting their academic needs is that they are not always viable for students whose homes do not have the space to designate for schoolwork, said Young.

“A family who chooses to home-school has a different setup than a kid that’s chronically absent, but it doesn’t mean they can’t be given that option,” she said. It’s up to each district to find the solutions that would best serve their students, she added.

Southern California’s Glendale Unified is one of the few school districts with a slight decrease of 1% in their absenteeism rate plus low excused and unexcused absences: 20.6% and 22.3%, respectively.

Last school year, more students met with the district SARB, said Hagop Eulmessekian, Glendale Unified director of student services.

To address increasing mental health concerns, every Glendale Unified school has a wellness center where students can take a break during the school day. If a student is experiencing behavioral challenges, they are transferred to a community day school where they take each class in the same room throughout the day while teachers rotate for different subjects.

“There’s no wiggle room for the students who kind of disappear” throughout the day, said Eulmessekian. “They get the same education, they get fed, they get additional support, whether it’s counseling or therapy, and then when we see they’re able to go back on our comprehensive campuses, we transfer them back.”

Oakland REACH’s Young encourages educators to think outside the box.

“We have got to get creative about these babies,” said Young. “At some point you have got to do something different. You have got to just say: ‘This kid’s at home, how do I still get them educated?’”

Back in Fresno, Muñoz has done a complete 180. As of March, his attendance rate is 98%.

“Counseling really does help a lot,” Pacheco said.

She also needed to learn skills to address the boy’s behavior, Aguayo said. “I think she kind of got the power she needed. She finally got control.”

Of 128 days, he’s only missed two, one of which was excused. Even on days when he’s sad about losing his great-grandfather and uncle, he goes to school, Pacheco said. In fact, he made a commitment at the beginning of the school year to attend every day.

“Now, he wakes up at 6 in the morning, ready to go,” Pacheco said with a grin. Muñoz, now 8, likes going to school to play soccer with his friends.

He is behind academically — the impact of not attending school for most of his first-grade year, Pacheco said. The school provides additional academic support through remediation classes.

“All he needed to do was attend,” Yeppez said.

Because of his current high attendance rate, the court dismissed the SARB case in December, and Muñoz ended counseling in February.

For other families with students not regularly attending school, Pacheco said schools and districts must help them by talking to them and figuring out the problem, much like Fresno Unified did for her, and families must utilize the provided or recommended services, such as counseling.

“I think it was a little bit of everything that helped mom,” Yeppez said. “She was willing to get the help, accept the help and make that change. She was willing to make that change for her son’s success.”

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Mark W 2 weeks ago 2 weeks ago

My children attend a top-rated LAUSD school, and my family highly values education. Both of them have almost near-perfect attendance. However, part of me often thinks, "why bother." So much discussion has been given to how the students have fallen behind due to Covid. However, I think there has been a total disregard for how the value of school attendance has also diminished. Few teachers have returned to the level of teaching they offered pre-pandemic, … Read More

My children attend a top-rated LAUSD school, and my family highly values education. Both of them have almost near-perfect attendance. However, part of me often thinks, “why bother.” So much discussion has been given to how the students have fallen behind due to Covid. However, I think there has been a total disregard for how the value of school attendance has also diminished. Few teachers have returned to the level of teaching they offered pre-pandemic, with some teachers quitting outright. Perhaps if educators focused on increasing the value of attendance, more students would see a reason for attending and paying attention.

Eva C. 2 weeks ago 2 weeks ago

I would love to see more research into safety concerns of students that are chronically absent. I'm glad to see it got a brief mention here as many articles on low attendance rates don't mention it at all. I have a highschooler with mental health issues that was already struggling with attendance which was around 80%. After a traumatic lockdown where another student was stabbed and died, her attendance as well as that of many … Read More

I would love to see more research into safety concerns of students that are chronically absent. I’m glad to see it got a brief mention here as many articles on low attendance rates don’t mention it at all. I have a highschooler with mental health issues that was already struggling with attendance which was around 80%. After a traumatic lockdown where another student was stabbed and died, her attendance as well as that of many other classmates, fell even further. It was weeks before some kids (and parents) were mentally prepared for a return to school.

Schools are also struggling to deal with bullying – I’m sure by kids that are also struggling. My child has now not been to school for 3 weeks out of fear for their safety since they are still being harassed by a student that had signed a behavior contract agreeing to zero contact. When I contacted school officials about that contract being broken, including she and her friends waiting for my child outside their classroom, video taping my child during class and posting it online, etc., I got zero response. We are now in the process of finding a hybrid alternative for her.

Our school had staff layoffs mid-year due to budget cuts, including a school resource officer, and teachers are being asked to do more and more. Campus safety is a huge concern and I believe it’s a factor causing educator burn-out. I believe that having to go to school every day knowing there is always the possibility for violence and school shootings has taken a toll on our young people.

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Restaurants in Moscow

     There are many restaurants in Moscow. Even the most demanding gourmets will surely find the restaurant to their taste in the largest city of Russia. Each restaurant presents a certain idea, conception, unusual way of the interior and menu decoration. Every restaurant features the unique style. The level of service in Moscow restaurants is getting so irreproachable that specialists believe some venues of the capital to be highly competitive with the best European examples.      Among the guests of Moscow Russian traditional restaurants are the most popular ones. A visit to such a venue could be turned into excursus to Russian history, since many restaurants are located in the very heart of Moscow, in old mansions, with which interesting stories and legend are closely connected. For instance, Godunov Restaurant is located in the premises that used to serve as a monastery refectory. Stylized furniture and decoration elements remind of it and create the unique atmosphere of the old days. The guests of the restaurants appreciate the atmosphere of Russian feasts: the waiters in national costumes serve pancakes with various fillings, meat and fish delicacies, and traditional Russian drinks. The public is entertained by folk songs, dances and old romances.      There are many restaurants in Moscow serving European cuisine. They feature elegant interiors, some of which remind of Imperial palaces, and others look like a studio of a modern designer. Menu offer traditional dishes of European cuisine as well as dishes prepared according to the authors' recipes. Some of the chefs working in Moscow restaurants are laureates of prestigious Russian and European contests.      Oriental cuisine used to be a fashionable novelty for Russian gourmets, but now it is taken as a classical one. Traditional sushi, soups, hot courses and desserts are offered in numerous restaurants of Moscow.      Vivid and vibrant restaurant life of Moscow combines the most fashionable tendencies and noble classics. It presents culinary traditions of different countries of the world, including the most exotic ones.

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The Top 10 Must-See Places in Moscow

1. red square.

3. The Moscow Metro

Perhaps you already know, but there is a great difference between Moscow, St. Petersburg, and all other towns and cities in Russia. Visiting the countryside is a great opportunity to travel the real Russia and to see the common life of ordinary people. The best choice for a one-day Russian countryside experience is the Vladimir and Suzdal tour.

Vladimir and Suzdal are small towns that are famous worldwide because of their great history and picturesque architecture with numerous UNESCO World Heritage Sites of the 12th century. Aside from golden cupolas of stunning churches and monasteries, you will experience a very rural real Russian outlook with bubbling streams and grassy meadows, chickens and livestock, and interesting and authentic local residents. All are a common sight on the streets, some of which remain unpaved. Be ready for a full-day trip and many unforgettable experiences during your Russian holidays!

•Road-tripping from Moscow to St. Petersburg

•Ecotour along the Volga River with visiting limestone quarries

•Real Russian countryside

•One day in a traditional Russian village

There is a great difference between Moscow, St. Petersburg, and all other Russia... The concept of this tour is to show you the real Russia with numerous small towns, pristine nature, abandoned churches and the life of people.

This tour does not include Golden Ring towns! Instead, you will see Staritsa town and Novgorod the Great, beautiful places to visit in Russia!

We will also visit an elderly couple living in a traditional Russia village. We will help them with their daily work - plowing the land (not by tractors, but by horses), caring for the livestock and cooking food in a traditional Russian oven… And surely we will taste some real fresh milk and eggs while they will be telling us about their common life, their habits, and the households.

The itinerary is perfect for those who are going to St. Petersburg. It takes only 4 hours to get there from Novgorod by a cheap local train.