188 The Hybrid Practice Reality Check

A hybrid practice can feel flexible and efficient, until the lack of structure starts creating problems.

When therapists move between telehealth and in-person sessions without a clear system, small decisions quickly turn into ethical, logistical, and clinical challenges. Questions about HIPAA, crisis management, informed consent, and scheduling all become harder when there is no defined default.

In this episode, I walk through what therapists need to consider before offering a hybrid counseling model. We look at how to decide between virtual and in-person care, where clinicians often underestimate risk, and why your policies matter more than your preferences.

This episode is less about technology and more about decision-making.

In this episode, we cover:

• How to create a clear default for telehealth versus in-person sessions
• Why informed consent and crisis planning matter in hybrid practice
• What therapists misunderstand about HIPAA, AI, and physical privacy
• How cognitive load and scheduling affect sustainability in practice

If your hybrid model currently depends on convenience or case-by-case decisions, this episode will help you build a structure that is easier to manage and easier to defend ethically.

Want to learn more? Check out this month's free resource from Kate Walker Training. 

Want deeper support? Inside the Step It Up Membership, we work through policies, documentation systems, supervision structure, and private practice operations in a way that supports both clinical integrity and long-term sustainability.

Get your step by step guide to private practice. Because you are too important to lose to not knowing the rules, going broke, burning out, and giving up. #counselorsdontquit. 

Transcript

Rent An Office Or Go Virtual

SPEAKER_00 0:00

Do you want to rent an office five days a week and do the mix and match in every other one? Or do you want to have a policy where maybe Monday and Wednesday are in person, Tuesday, Thursday, Friday are virtual? What is your default? That is the ultimate decision.

The Hybrid Practice Reality Check

SPEAKER_00 0:22

Welcome to the MS Therapist, building practices. This one's a little different. Today we're not talking about rules or systems or what the board requires. We're just asking a question. Is the practice you're running right now actually the practice you want? Not the one you fell into, not the one that made sense five years ago, the one you'd build if you were starting today. This is a gap analysis episode focused on hybrid practices. And it's for the clinician who's been too busy to stop and ask that question. Well, we're stopping today. Now let's get to work. Hey, I'm Dr. Kate Walker. Welcome to your Tuesday coaching. Today we're talking about a hybrid counseling model. So telehealth and in-person. It's funny because I think about hybrid models and how this wasn't even a thing before COVID. Like we really didn't have any sort of frame of reference. In fact, as a counselor educator, we were like, no, you know, this is absolutely just not a great way to do things. And then COVID happens. We're like, oh yes, absolutely. Everybody, we've got to figure out how to do this. So the necessity, of course, made everybody kind of get their act together in more ways than one, right? We all had to find affordable telehealth HIPAA compliant platforms. We all had to sort of understand the cognitive load of doing telehealth. I remember before the technology caught up, I would do a session and my clients were pixelated, 100% pixelated, but I could hear their voice. And so I would be staring at a pixelated screen, but they reported they could see me just fine. And so all of those things that I have kind of been ironed out contributes to your decision making. And that's my goal for you. So for your coaching today is that you leave here with one action

Why Telehealth Works So Well

SPEAKER_00 2:34

item. So the hybrid model, let's look at the pros first. Number one, no commute, no office means you save money, right? You're saving money on rent, you're saving money on gas, you have better attendance for you and your clients. So again, that's a financial thing, but it also applies to the treatment plan, right? If you have a client who's consistently coming and they're able to complete their treatment plan or accomplish the goals on the treatment plan, that's a wonderful thing. You can serve rural, you can serve military. And in my case, when I was working in the Houston area, a lot of my practice was devoted to offshore. So I could see folks who were working offshore on those split shifts. So telehealth absolutely made it easier to do that. So we're serving more people. It's accessible for clients and not just clients with disabilities or who maybe are sick. Like I've got a little cold today. I would love it if I was in therapy, if I could just do this via telehealth and I didn't have to go to the office. But also for parents, right? How many of you see an individual adult who can't attend because they have a sick kiddo? So it's great for that. And then, of course, supervision. There are no restrictions for supervision via telehealth. And that includes you MFTs out there who had the restriction of telephonic supervision. That's gone. There is no restriction on doing supervision via telephone or via telehealth.

Tech Fails And Crisis Protocols

SPEAKER_00 4:09

So the cons, the failures, right? Having something in your informed consent that helps your clients have a plan B. What is your backup plan if the technology fails? So if you had a situation like I had and you're just talking to a pixelated screen, would you cancel the session? Would you encourage the client to log in, log out? I know back in the day it made, you know, my heart was pounding. I'm like, oh my gosh, what do I do? And now I'm so much more confident to be able to say, hey, can we just try this again, log out, log back in, and keep the session going very smoothly. And I believe our clients are the same way. Everybody's used to it now. But that doesn't mean you don't have a backup plan in case something happens with your software. Crisis situations, and this is one of the things we talk about in supervisor training, teaching your supervisees and you owning what are your procedures if you're watching someone on telehealth and you see someone sort of lurking in the background, or you uh notice that they are exhibiting symptoms of a stroke, or they just pass out, right? Something that you could follow and teach.

Location Laws And Ethics Updates

SPEAKER_00 5:26

And that brings to client physical location. So you may have a rule with your license that says you must know the client's physical location, or you may not have a license that requires that. But a really cool thing I saw today, the ACA, uh American Counseling Association, has put out their call for comments on the 2026 code of ethics. This is the first time it's been updated since 2014. So I looked through it today. I just kind of perused and they did great. I saw lots of information about informed consent and telehealth. And I didn't do a deep dive yet, but I am curious if that is one of the ethics that they're going to call for, that we, whether our license rules say so or not, that we confirm the client's physical location with every session. I know back in the day, I keep saying that, it was only like five years ago. But anyway, five years ago when we first started this, I would not only ask the client's physical location, but because my clients were traveling so much, and these are for my clients in Texas, I would ask for a cross street, you know, because if my client was suicidal or had some uh something going on where I needed to call emergency vehicles or emergency services, I didn't know where this, I don't know Abilene. I don't know, you know, the east or the west side of Houston, right? So I would want to know not only where my client is located, but what are significant landmarks and cross streets. So again, that may be something you're totally comfortable with, but if you're a supervisor, that would be something you would want to teach to your supervisee to go beyond just an address. Also to verify so you're not breaking other states' laws, right? I'm talking to you, traveling therapists. And I did this. I would give sessions from Maine. I was giving sessions from New Hampshire, I was giving sessions from, you know, the Blue Ridge Parkway. And so understanding that not every state is okay with that. Not every state says, okay, you are in uh Tennessee, so it's okay for you to see your clients virtually in Texas. They may establish the counseling relationship in Tennessee, and that was the Smoky Mountains, not the Blue Ridge Parkway, but I I digress. So be sure if you're going to be traveling, and this is even internationally, that you understand if where your feet are planted, if that jurisdiction, that state is okay with you delivering services. Texas is kind of funny, right? We've talked about this before. If your feet are in Texas, but your clients' feet are not in Texas, they don't even consider that counseling. They have zero jurisdiction. They're like, no, that's not our problem. We're just gonna leave it up to the state where the client's feet are located. So there are lots of good reasons to make sure you're verifying their physical location. HIPAA compliance. Lots of people think this is just about a BAA with your software. And it isn't. If you have taken my HIPAA course or if you've gone onto the HIPAA website and taken their free course, you can hardly throw a rock without hitting a free HIPAA course out there. So everybody should take one. And supervisors, you should make your supervisees take one. It's not just about a BAA with your software, right? You can have a BAA with your Zoom and it's really affordable, like free. But if you are in a room where people are walking past or there is zero, like your walls are made out of paper, that's called physical security, right? So having physical HIPAA violations, that's like visiting someone in the hospital and they put the computer with all the patients' names and information in the middle of the hallway, right? Even though that software may be HIPAA compliant and will sign a BAA with the hospital, the fact that physically it is in a location where it is not confidential, that's a problem. So if you are supervising or if you're considering this idea of virtual, make sure you go beyond just the BAA and the software and focus on the physical space.

Free Bonus Fee Reset

SPEAKER_00 9:59

Hey, quick pause. This month's free bonus is called Stop Working for Free, the Therapist Fee Reset. And it's updated for the clinician who's been adding value to the profession without making sure their practice actually supports their life. It'll help you see the full picture of what adding supervision, adding teaching, adding consulting really adds to your practice. Not just the hourly rate, but the professional case for making the move. Grab it free at KateWalkerTraining.com/slash bonus. Now back to the episode.

HIPAA Privacy And AI Settings

SPEAKER_00 10:38

All right. When we talk about the BAA, when we talk about confidentiality, almost 100% of the time now we're also talking about AI. And so, like with this Zoom call, every single time I have to decide if I'm going to turn AI on or turn AI off. And with my confidential Zoom, when I do client sessions, it's AI off. I don't use AI. I don't, I mean, it's my choice. I don't have anything against it. But understanding if you're using a platform where it starts automatically and you, and I'm talking to you supervisors, if your supervisee says, Well, I have no control over that, then ask to see the informed consent. Make sure that you are able to verify and document that clients have the ability to opt out of AI. That's also it's in the new code of ethics for ACA. I was really happy to see that. Finally, is it clinically appropriate? So maybe you see small kids, maybe you see certain diagnoses where telehealth is not appropriate. Maybe you do groups or couples in families and it's just not going to work. I know with me, if I was doing couples and one was offshore and one was in town, you know, there was that, okay, let's hope and pray the technology works, because if it didn't, you know, then what? Right? Goes back to your informed consent. If one person's technology isn't working, are you going to continue the session? I even thought about, you know, I don't know how many times you guys in real life have had a session booked, and then you walk out to the waiting room and it's somebody else. And you're like, oh, this is awkward because there's the partner or there's the parent, and it's not the person who was actually signed up to have therapy that day. Well, the same thing happens with telehealth. I will get someone who signs up, and then when it's time for the session, I'm like, oh, I don't know you. We haven't met. What is happening right now? Am I going to continue the session? So think about is it clinically appropriate if you are seeing couples and families and that backup plan in case the wrong person shows up. And of course, we've got insurance considerations for the traveling therapist. I follow a traveling therapist thread online on Facebook, and I notice that's becoming a bigger and bigger deal with insurance asking you to check a box if something was telehealth or not, and it affecting the payout.

Policies That Make Hybrid Sustainable

SPEAKER_00 13:12

So your action items for today, what I would challenge you to do is who decides on telehealth? Is it you or the client? So your action item is write it down, put it in your policy for your practice. Even if you're a solo practitioner, I encourage you to have a set of policies and procedures. Who decides telehealth? Is it just a convenience thing? I mean, that's what I did. I don't know if it was right or wrong, that it seemed to work okay. It would be like, oh, you're running late. Well, just pull over in a parking lot, let's do telehealth. Okay, you know, but I never got into a situation where a particular diagnosis was the issue, or, you know, if the client was in crisis, I mean, honestly, I probably got lucky. So you leaving this with some sort of a policy on who decides telehealth, the next would be to look at your systems for both. Think about, for example, your late cancel no show policy, right? So for me in person, in in real life, when I had a lobby and I had someone who would call me, say, hey, your client's here, you know, for me, that client bought that hour and they pre-purchased it. And that was part of our deal with the late cancel no show. I didn't need to know if you were running late because you had already purchased the hour. If you want to show up for the whole session, great. If you show up for the last 10 minutes, well, you get 10 minutes. So making sure your policies for your in-person are the same as for virtual. Do you give someone a call? Do you not give them a call? Do you stay online for the entire hour or do you log off after 10 minutes? What is your policy if two people show up but there was only supposed to be one? Or one person shows up and there was supposed to be two. Or and the the completely different person that you don't even have paperwork on. Another action item would be to just be aware of the cognitive load. If you are just gonna rent an office and you know your one o'clock is in person, your two o'clock and three o'clock are virtual, your four o'clock and five o'clock are in person, just recognizing that might not be great for you personally. I mean, honestly, when I was doing virtual sessions, you know, six hours a day, I would almost be nonverbal by the end of the day just because of the screen and the staring. And that was not good for me. But that's all I do. It's all I do. I don't do any in person. I'm just very mindful of my schedule. Rental cost, that's pretty obvious. You know, do you want to rent an office five days a week and do the mix and match and every other one? Or do you want to have a policy where maybe Monday and Wednesday are in person, Tuesday, Thursday, Friday are virtual? What is your default? That is the ultimate decision. So for me, for example, my default, what I do all the time is virtual. It would take something very, very serious for me to break my default and say, okay, I'm gonna rent an office and see this client uh on Mondays, right? It would have to be something having to do with the diagnosis, perhaps, or the modality or their level of crisis. So think about what is your default and then what is your criteria if you switched to the other. So if your default is virtual, how do people get you in person? Is it because of the day of the week, right? If they say, well, I can only come on Tuesdays, you're like, lucky you, that's my in-person day. Well, then do you switch to virtual? And it's okay if you do, but again, just making sure that you document. It could be for an intake, like you do all of your intakes in person. It could be because you see little kids. When you see little kids, doesn't matter what day of the week, that's going to be in person. So I would just challenge you to create an action item for yourself. If this is something you're tossing back and forth about what you want to do virtual in person, or like what we're talking about today, a hybrid. What is your criteria when you would make exceptions? So just to review who decides telehealth, you or the client? Are your systems equal? So things like your late cancel no-show policy. Are you considering the cognitive load on you? Rental cost. Are you going to switch by day or by client? So switching on and off Monday, Tuesday, Wednesday, then Thursday, Friday, you do something else. And then deciding what is your default and under what criteria would you make exceptions to that default.

Next Steps And Closing Thanks

SPEAKER_00 18:00

If this episode got you thinking seriously about maybe adding private practice, supervision, consulting, a new certification, something to your practice that could enhance your life and the bottom line, your next step is simple. Grab the bonus at Katewalkertraining.com slash bonus. It's going to walk you through exactly what you need in place before you add that extra thing this month. And if you're ready to make it official with starting supervision, it's easy to do. Just go to KateWalkertraining.com slash supervisor training. If you love today's episode, be sure to leave a five-star review. It helps other badass therapists find the show and build practices that drive. Big thanks to Ridgley Walker for our original fun facts and podcast intro, and to Carl Diamella for editing this episode and making us sound amazing. See you next week.