There are many reasons to conduct nutrition counseling in a client’s home. The most obvious is that homebound patients can’t come into your office. If you work for an infusion company, you may consult in the home for TPN or tube-feedings. Other reasons are for pediatric early-intervention programs where most services are provided in the home. You may offer kitchen makeovers that require your being in the kitchen, and finally, you may want to avoid the overhead costs of maintaining an office.
Home is where one starts from.
T.S. Eliot
Good fences make good neighbors.
Robert Frost
There are advantages and disadvantages of doing your counseling in the client’s home and some issues that are unique to this setting. The home setting can present ethical issues and concerns for your safety and can increase or decrease the effectiveness of your counseling.
Advantages of in-home nutrition counseling:
Being in the home gives you the opportunity to look at the environment in which the client does much of his food storage, preparation, and eating. You can quickly get an accurate picture of what he has in the refrigerator and pantry. The physical setup of the kitchen and dining area may impact his nutrition in ways you would be unable to assess just by talking with him in your office. For example, there may be no table to eat at. Some families do very little food preparation at home, and mostly use take-out options. This may be evident from the lack of cooking utensils or from a large stack of pizza boxes.
Assessing the client’s economic resources may be easier in the home. For example, many people, in an outpatient clinic, will not admit struggling to afford food. In the home, this will likely be evident. You can then include budgeting advice and discussion of community resources. On the other end of the economic spectrum, a lavish home or household staff gives you a very different image.
If you do label-reading with clients, it is easy to begin with the items they have already. You can discuss portions using their own measuring cups, plates, glasses, and bowls.
Seeing the home can be useful with pediatric-feeding visits. Is there a high chair? Does the home have a dining area that accommodates family meals? Is it physically feasible and safe to involve the child in meal preparation?
There are both pros and cons of other people being in the home during the visit. It gives you the opportunity to meet family members who may influence your client’s eating. For example, meeting with the person who shops for the homebound individual can be valuable. On the other hand, these other people can easily be distracting — especially if they are children.
Disadvantages:
In someone else’s home, you can never be certain that you will have an uninterrupted session, even if she promises it. You can ask her when a quiet time would be for her and ask that phones and TV be turned off during the scheduled time. Making the time very clear may nudge the client to do what she can to minimize disruptions. For example, “I will arrive at 1:00, and we will have an hour.” It can be harder to adhere to time limits for your sessions in the person’s home. For clients who seem to have difficulty with time limits, see Tip # 21 for ideas.
You don’t have access to all the resources, such as handouts and food models, that you have in your office. You can bring some with you, but it’s easy to misjudge the direction of the visit and not have the handouts you need.
Home visits take up more of your time. You have to travel to the home and find parking. Often, the small talk at the beginning of the visit can take longer in a home setting. For self-pay clients, it may work well to charge by the hour rather than by the session and to figure in travel time.
The final potential negative is safety. You don’t know what you’re walking into. Many dietitians don’t do home visits unless the client was referred by a trusted source or they have met the client first in an office. If you don’t have an office, meeting in a coffee shop or library is safer.
What it does to the relationship:
The quality of the relationship between you and the client impacts your effectiveness. Conducting your nutrition counseling session in the client’s home affects the dynamics in several ways. There is a tendency for the visit to feel a bit more social and less professional. It’s best to do what you can to steer the visit toward a professional one.
Here are things to be aware of…
- Remember that, in addition to being a client, the person is also a host. Your role is complicated by the additional position as guest. Depending on how the person was raised, this may mean she can’t help but offer you a beverage or food. It can be tricky to remain professional by not accepting and yet not insulting the person if hospitality is an important part of her identity.
- It can be more difficult to maintain control of the session when you are in the client’s space. As with any session, you may guide the direction of the session in ways you judge to be most useful to the client. This is still part of your job, even in this setting.
- You can let the client decide where you two will sit. It’s her home, and this encourages a sense of choice (Tip # 47). The only exceptions may be if you are concerned about the cleanliness of some seats or if it would be easier to review handouts or labels in another location.
- There is the potential for misinterpretation of your presence in the home by the client or family members or neighbors. Be ready to explain your role if needed. Some home health patients may get confused and expect you to make the bed, run errands, etc. It will be useful to be aware of the rest of their team and refer to them.
There are some subtle things you can do to set the tone for a professional visit. As you would in an office visit, limit the range of your small talk to things like the weather and other common light topics (Tip # 115). Keep your comments and focus on the person, not the home. It may be tempting to take a look around or to comment on some quality of the home or decorating. This may be perceived as “checking them out” or even judging the client and could waste time. Only go into rooms you need to. Some dietitians make a point of timing their visits to the restroom so they won’t need to use their client’s bathroom. This avoids what may feel intrusive to some clients.
You are in the client’s world. An advantage of this is the client doesn’t feel like an outsider as he might in your office. On the other hand, you are on his turf, and it can take an effort to both respect this and direct the session professionally. A down side is that you may find yourself overwhelmed and struggle to keep track of your professional knowledge, etc. Have your goals and expectations clear before knocking on the door.
Talk about it:
The clearer you are with your clients about expectations and your role, the better the visit will go. When at all possible, discuss ahead with the client what you expect to accomplish in the first visit, what you will need from him, the time of the visit, and who will be there.
For ongoing clients, you can begin the second session with a brief discussion of how it is going. You might even mention that home visits can be awkward for some people, especially if you sense some discomfort on either your or the client’s part. You can periodically check on how it is working for him.