I worked in home health as an SLP-Assistant for 6 years. After spending scorching hot summers driving from one side of the city to the other, driving 30 minutes to a client’s home only to find out they’re not home, and never being able to use the trunk of my car due to the pile of toys and materials I lugged around everywhere, I thought working in a clinic would be a dream. When I entered the field of ABA I continued working in home health for several years and only recently moved to a clinic based position. Using what I’ve learned in this transition, I’ve created this guide to help you decide what setting might be best for you.
One of the great things about my home health and clinic experience is that they are very evenly matched. Both were salaried, fulltime positions with almost identical salaries. The billable hour requirement was the same for both, 25hrs per week with an hourly bonus for every hour over 25. While I had very good reasons for leaving my first company, I will leave that out of it and only compare the points specifically related to the setting.
The ideal winner for therapy quality would be a combination of center based AND in-home therapy. I’m lucky enough to work at a clinic that incorporates home or community based therapy when needed, and when I was a home health therapist, many of my kids also received center based therapy in addition to our in-home therapy.
In a center based setting, you can make great progress, have almost complete control over the environment, and all your clients and therapists are right there in the same building. However, there is typically less focus on adaptive skills and, even if you incorporate a lot of naturalistic play, is not comparable to working on skills and behavioral problems in the home and community. Our kids often have generalization issues, so working on and mastering skills in only one environment is not necessarily going to generalize across places. Another concern is with so many therapists in one building, it is very easy for the people doing the schedule to put any therapists (whether they’re trained or not) you’re your client if their regular staff is out instead of canceling the visit.
When a client only receives in-home therapy, generalization will be great and it is much easier to build rapport and trust with a family in home health where you are on hand to train parents, answer questions, and offer support on a regular basis. However, you lose the advantage of having a structured and controlled environment to analyze and target behaviors.
It was a very strange thing when I started working in a clinic… with a bunch of other people… all day long! I was used to being in my car by myself all day and I was ok with that, but working in a center with co-workers is so much better.
In home health, you are on your own except when you are supervising an RBT. This could be a good thing if you are an experienced therapist and more of an introvert. Most home health companies will try to establish a company culture and try to make you feel more a part of a team, but it often falls short. In a clinic setting, there is usually a stronger company culture and a definite team feeling. You also have a bunch of other BCBA’s that you can bounce ideas off and get advice when you struggling with a particularly difficult case. It is great working with people, but one thing to keep in mind is that you will be way more distracted in a center based setting. In home health, you can work on your reports and paperwork at home, but in a clinic, you have to decide if you want to continue working on that report or go with everyone to get Starbucks, or start chatting about your weekends, etc… With headphones and a little willpower you will be fine, and in my opinion it is still better than being out there on your own.
Just like the section on co-workers, this will greatly depend on the company and people you work with and your own personality. If you are experienced and just want to be left alone to do your job, then home health would suit you better. If you are new, need a little more support, and have lots of questions, then center based would be better for you.
In general, in home health you will have greater independence. You are out there on your own doing therapy. You get to make your own schedule, do what you want when you want, and if you are getting your hours in and making progress you will mostly be left alone. In a clinic setting, your boss is right there all the time. You will receive more support, but there is still the potential for less independence and more 'being managed' whether you asked for it or not. However, this is greatly dependent on who you work with.
While there are clear pro’s and con’s to both work settings in this category, I’m going to give the win to clinics.
In a center based setting, all the RBT’s are right there for you to observe, train and answer questions. This sounds great, but when you walk through the therapy area, you often get pulled in 5 different directions by a bunch of different questions. Also, since your right there in the center, there is less importance placed on training which leads to therapists being less self-sufficient. And line therapists or RBT’s have the same benefit from working in a clinic with their co-workers as you do, they are much more likely to get distracted talking to their friends. But that also means they have more support from their co-workers if they’re struggling with a behavior or program.
In home health, you are working one on one with the therapists and can devote all your attention training them with one client. Also, since you are sending therapists out to work on their own, there is a lot more emphasis placed on training and therapists learn to be more self-reliant. But, you have a lot less interactions with your therapists which could lead to things being done incorrectly. You are also on call anytime your therapists are in session. You might not work at 7pm, but if your therapist is in session and they call you with a question, you should take it, regardless of what you’re doing.
This sounds like center based therapists have a lot of negatives for being the winner, but most of those negatives can be shaped up with better training and company policies. Nothing can replace being present and available for all of your client’s sessions at the same time.
While the above topics are very important, there are a few other miscellaneous things to consider when choosing which setting fits you better.
One of my favorite things about home health, something I still miss even though I love working in a center, is having a flexible schedule. As a home health BCBA, I had a set number of hours to hit each week, but outside of that I could go to work when I wanted, schedule Dr. appointments and lunch with friends when I wanted, and could stay home and work on paperwork if there was bad weather or if I felt a little sick. This one aspect of working in home health could possibly negate everything above, that’s how awesome it is to not be tied to a 9-5 schedule. You can work pretty much when you want in home health, but for about half of your hours you will need to go in-home to supervise and there is often lots of driving involved. I’ve spent so much time stuck in traffic, getting lost, and sitting at the mechanic getting my oil changed EVERY month. And sometimes you go through all of that driving and traffic to arrive at a client’s home and find that they are not there, or the client has a fever and they forgot to call you, so then you’re stuck 40 minutes from home with a 2-hour gap in your schedule. You also have no bathroom (and have memorized all the Starbucks and McDonalds in your area for your bathroom trips), have no fridge or microwave, and probably have tendinitis in your shoulder from carrying your giant bag of materials, computer, and basically your whole office into every visit.
In a clinic, you will not have the wonderful flexible schedule that you do in home health, you will likely need to arrive and leave work at a specified time and request time off to schedule Dr. visits and other necessities of life. But don’t despair, there are some great benefits to working in a clinic. There is no driving except going to and from work. Seriously, my 15-minute drive to work is so wonderful after driving hours every day for 6 years! Clinics also have kitchens, with giant fridge’s and microwaves and sinks, and break rooms to sit and eat! You may think it is crazy to get so excited about this, but it is amazing when you’re used to using gas station microwaves to heat up your leftovers and then have to find a house with the biggest tree in the front yard to eat your lunch in the shade… until the owners come home and give you strange looks for being parked in front of their house eating your Lean Cuisine. And then there is the bathroom, a clean, normal bathroom that you can use whenever you want. Oh, and clinics have toys, lots and lots of toys. There are swings hanging from the ceiling, a playground outside, a sensory room with sand and rice, a giant indoor trampoline, and now we just got a carousel (not an electronic one, you have to push them, but still it’s awesome!).
Deciding the best setting to work in will really depend on your personality, what’s most important to you, and the company that you work for.