Providing a mobile service at a patient's home

A guide for osteopaths who want to provide a service at a patient's home, including obligations, funding and risk management.

Why provide home visits?

Home visits may be suitable for a variety of reasons including where, for medical or social reasons, a patient is unable to attend practice or, because it is the preferred operating model of a practitioner. Delivering clinical services in the home of a patient naturally raises some considerations that may not apply in your own practice setting, or may require you to heighten your awareness to them outside of a familiar environment. You must uphold your own safety at all times.

Whether you practice at a clinic or provide home visits, your obligations as a registered health practitioner remain the same under AHPRA regulation.
Maintaining compliance can be a challenge, because it may require you to consider aspects of the environment, patient’s home or other factors that you can more easily mitigate in your own clinical setting.

Before you agree to visit

Medicare provider number
Your Medicare provider number/s are associated with locations from which you provide osteopathic services. If a patient wishes to obtain a rebate for osteopathy services, you will be required to have a Medicare provider number that enables you to provide home visitations. This could be linked to your residence or other physical address (e.g. your primary clinic).

If you do not have approval for a Medicare provider number that enables home visits, you should inform the patient that they will need to pay privately in full for the home visit, as well as for any diagnostic imaging required.
Third-party funder approval

Some third-party funders and compensable injury schemes allow osteopaths to provide rebated home visits within their typical schedule of fees. Irrespective, preapproval may be required before a rebated home visit can occur. If you believe an approved patient may benefit from a home visit, or if a home visit is requested, contact the case manager or agent managing the claim. Failure to seek pre-approval can leave you out of pocket for any expenses you have incurred in providing a clinical service at a patient’s home.

Patient history and behaviour

Does a patient have a known history of aggression, inappropriate conduct or are there other general safety concerns? If yes, this would indicate potential for interpersonal risk in a home setting where you are working alone. Aspects that can compound risk include:
•    Being out of mobile phone range
•    After hours work
•    No designated person to check your progress, wellbeing or movements, or protocols to follow if you are delayed or there are other general concerns.

Ensure you weigh up the risks to your personal safety and wellbeing. Do not proceed if you have significant concern.

Clinical equipment and supplies

Any clinical service you provide at a patient’s home must meet safety requirements and be of sufficient quality that you meet your duty of care obligations as a registered health practitioner. You are better off over prepared for a range of clinical scenarios than underprepared. This includes gowns, towels, tables, gloves and any other equipment in accordance with your scope of practice and clinical focus. Your professional risk may increase and you may be liable if you proceed to provide a clinical service without appropriate clinical supplies.

Income protection insurance

Your professional indemnity insurance covers product liability, professional liability and public liability only. If you have a vehicle accident in the course of traveling to a patient’s home, this will be outside of the scope of professional indemnity. You would require a different type of insurance, known as income protection insurance to appropriately manage the risks of your travel to a home, between homes and to your own residence or practice. This insurance gains importance if you are traveling by night in rural or isolated areas. Guild provides a range of insurance types. Please phone 1800 810 213 to make an enquiry.
Property suitability

Some properties present increased risk due to damage, overcrowding, space limitations, hoarding, squalor, lack of maintenance and/or the presence of domestic animals. These issues can pose significant work, health and safety risks to you- not merely in terms of trips, slips and/or falls but also obstruction of exit routes, fire and electrical hazards.

Ensure you relay your expectations with regard to the condition of a property should a clinical service be provided, including that it be reasonably clean, orderly and/or maintained with no obstructions.

You can withdraw your consent even after you have agreed to provide a clinical service at a patient’s home, if on your arrival, your opinion of the safety of a property is downgraded. Refer to Osteopathy Australia’s Animals in Clinical Settings Practice Briefing for further advice and/or guidance regarding animals and risk.

Loss of other business

If you practice at a clinic, or provide services from your own home, you should consider any opportunity costs associated with a home visit, such as how many patients you could see in the time you may take to travel to a patient or between patients.

Claiming tax deductions for mileage

If you regularly perform home visits over moderate distances in your own car, only the first 5000 kilometres are tax deductable per car where diarised under guidelines from the Australian Taxation Office. Accordingly, you are within your rights to weigh up the expected financial benefit to you against any expenses required to facilitate a home visit.

Once you visit

As in a clinic, you are required to adhere to all applicable AHPRA regulations at a patient’s home, such as:
•    Patient confidentiality/privacy.
•    Informed consent.
•    Professional boundaries.
•    Patient safety.
•    Clinical records.

Confidentiality, privacy and clinical records

If a patient does not live alone and there are others present in the home during your visit, patient privacy can be compromised. Only if a patient consents in writing should another member of the household or person be present or privy to patient information. Ensure you work with the patient in a private area of the home, remembering to close doors, windows or other openings that could lead to unintended disclosure of clinical or personal information.

All clinical records, including health and physical assessment findings, diagnostic reports, treatment plans, clinical notes and referral documents must be maintained and filed in a way that protects patient privacy irrespective of where you provide an osteopathic service.

Treating sensitive areas, professional boundaries and informed consent

Treating sensitive areas of the body at a patient’s home can blur boundaries between clinical practice and inappropriate intimacy and you should be attentive to how a patient interprets the clinical techniques you use and the intention of their use.

Consistent with the Osteopathy Board of Australia’s Sexual and Professional Boundaries guidelines, you should, whether at a clinic or a patient’s home:
•    Only provide services that you are competent in, informed by evidence on the basis of sound clinical rationales
•    Obtain prior patient consent if anyone else, including a student is to be present during an examination and/or treatment
•    Dress professionally so that your intentions are not misinterpreted
•    Explain your techniques before use and provide opportunities for questions
•    Offer a patient the opportunity to bring a support person, family member or chaperone if assessing or treating internal or sensitive areas
•    Gain written consent before a procedure commences, while a patient is clothed
•    Allow a patient to undress in private
•    Provide appropriate gowns, towels or coverings
•    Use examination gloves wherever treating internal or sensitive areas
•    Be attentive to signs a patient is uncomfortable or has withdrawn their consent
•    Not continue where consent is uncertain or withdrawn
•    Not allow a patient to remain undressed for any longer than is needed for examination and/or treatment
•    Keep appropriate records of sensitive or intimate area treatment
•    Be sensitive to cultural diversity.

Child welfare and domestic violence

Your obligation to uphold the safety of minors and other vulnerable people continues at patients’ homes. You are more likely to be exposed to events or incidents that you may be required to report within a home than at a clinic.If you witness domestic violence or physical assault, whether directed toward a patient or a patient toward someone else, you are obligated to phone the Police on 000 in keeping with your duty of care as a registered health practitioner. Risks to child welfare, such as abuse (sexual, physical or serious emotional) and neglect (inadequate provisions) should be reported to your state based child protection authority as a matter of sound practice.

If you are a designated mandatory reporter of child abuse and neglect, including osteopaths in the Australian Capital Territory, New South Wales, Northern Territory and South Australia, you are legally required to make a mandatory report. Significant penalties can apply for failing to do so where there are grounds.