Category: Neuropsychology

FAQ Regarding Psychological Practice in Geriatric Facilities

Over the last ten years, I have received multiple questions regarding psychological services in nursing homes and assisted living facilities.  Many of the questions are difficult to answer, due to the actual naming of a practice or individual.  What follows is a general fAQ for administrators and social workers to identify suspicious professional practice::

1)  They are marketed as appropriately trained psychologists when in fact most have no formal training in geriatrics, let alone dementia assessment and treatment. This is defined as “unethical” practice by the American Psychological Association.  Psychologists must have formal training in any population served or intervention offered.  My suggestion is to examine the psychologist’s vita for appropriate training.  Do not trust what marketing people have to say regarding qualifications.  See for yourself.

2)  The psychologist is working three to five days a week in your 120 bed facility. This is a recipe for ethical disaster, if not overt malpractice.  A 400 bed nursing home is not likely to offer more than 2 full days of work for most psychologists.  If the psychologist is not trained in neuropsychological assessment, one day should be plenty!  As the kids say-do the math.  Are there more than five or ten high functioning (mentally ill) residents that could profit from insight-oriented psychotherapy in your building?  Probably not.  Psychologists trained in outpatient work will fill their clinical time by treating demented residents.  It is imperative that they generate the numbers that please their respective corporations.  Medical necessity is reduced to a vague consideration.

3)  The psychologist treats dozens of residents, yet does not obtain written permission to treat any resident. A psychology corporation executive told me that an attending physician’s medical release covers psychologist’s liability as well.  This is not the historical position taken by the Florida Dept. of Health, Medicare, or the American Psychological Association.  Psychology is an independent profession that requires written permission to treat, and offers informed consent regarding the nature of the treatment.  As explained to the executive, I worked many years ago as a neuropsychologist for a company called Apogee.  A Medicare audit discovered that Apogee did not obtain written permission to treat their nursing home patients.  Medicare demanded a full refund for each patient that had not signed a release.  The company folded like a tent in a hurricane.

4)  The psychologist assigned to your facility changes every year or two. This reflects the fact that most psychologists hired by psychological corporations are young graduates.  Most have no experience in long-term care, have no formal training in dementia care, and have little desire to make a career in this area.  On the other hand, some older psychologists gravitate to geriatrics after failing in their primary area of interest.  This actually describes two owners of a local geriatric psychology corporation.  Both the young and old clinicians are similar in the sense of being inadequately trained.  They differ in that the young clinicians will move on to their chosen area of interest, and the older will cling to nursing homes as their last resort.  I do not believe either group adequately serves the interests of the residents.

5)  The psychologist/marketer offers to wave Medicare copays and treat managed care residents for free. An offer to wave Medicare copays is definitely not kosher.  Medicare rules for participating providers are clear that we must bill for our copays a total of three times!  I must admit that if I receive a letter refusing to pay, I let the matter drop at that point.  Technically, I may be in the wrong.  To tell others that I will not collect copays whatsoever is another matter.  As for free treatment of Medicaid and managed care residents, I’ll believe that when I see it.  I suspect that unpaid Medicaid patients are cured in two sessions, while all the paid residents require years of follow-up.

In summary, it is not difficult to identify unethical behavior or actual malpractice in your facility, but first you must be educated regarding the behavioral markers.  It is important to always keep in mind that psychological corporations are in your building to make money-period.  If your goal is to have all the Medicare residents billed as frequently as is allowable, I believe that you will not be disappointed with most psychology corporations.  If your goal is effective and ethical treatment of your residents, I fear you will have to look for individual experts and small dedicated group practices.  Lastly, I offer Holzmacher’s general rule of nursing home marketing as a helpful guide:

The potential for fraud and abuse increases in direct proportion to the slickness of the marketing, the frequency of the marketing efforts, and the reticence to supply the names and skills of those who actually perform the work.

Good luck!


Business Logo for Psychological and Neuropsychological IssuesThere is a century old debate in psychology regarding the method the brain employs to store memories.  A recent article in the Scientific American (February, 2013) contained an article that spoke to this very debate.  It attempts to revive the theory that the human brain stores memories in specific neurons.  Put another way, any memory encoded is programmed into a discrete cluster of neurons within the brain.  For example, the authors reported they discovered the exact brain cells that encoded the image of Jennifer Aniston (actress) in someone’s brain.  Quite impressive.  The competing theory is that the features of any memory are distributed across the brain.  Rather than being stored with Ms. Aniston in a particular area of the temporal lobe, this same area is conjectured to be the site where the location of each sense memory is stored.  For example, the name of Jennifer Aniston would be stored in the area of the brain that retains words, her face would be stored in a different area that stores faces, and her body type would be stored in an area that retains spatial details.  This retrieval strategy has similarities to the library card catalogue system.  The actual books (content) are not stored in the library cards, but rather the cards store the location where the content may be found.

This article is perhaps most notable for its contradictions than it is for presenting new ideas.  It is very seductive to believe there is an exact area of the brain that serves as a storage sight of each memory.  It corresponds to the way we store objects in our everyday life.  Nothing is easier or more attractive than to relate complicated processes to our everyday experience.  Contrary to this end, the authors (to their credit) admit that brain cells that fired to a picture of Jennifer Aniston also fired to a picture of another blond actress.  This tends to disprove their contention of discrete cellular representations of each memory.  Another objection advanced by the authors is that there is not enough brain cells to encode every new experience in the human brain.  Essentially, our brain would fill with memories until the bucket could hold no more.  The authors believe the solution to this contradiction is that a “typical person remembers no more than 10,000 concepts.”  Their notion of “concept” is problematic, even beyond their vague definition as to what defines a “concept.”  The notion that all information regarding objects and their relations should hover around 10,000 bits is difficult to accept.

The authors advance another contradiction as proof of their theory.  They cite the famous case of a man whose hippocampus was surgically destroyed.  The hippocampus is a medial temporal lobe structure where the authors believe all our memories are stored.  This unfortunate man could not encode new memories at all, but he enjoyed complete retention of all his old memories-until the time of the surgery.  This strongly contradicts the authors contention of exact cellular storage of each memory.  Given that the hippocampus was destroyed by a surgeon, this man should lose all his old memories as well.  He would literally become a tabula rasa; incapable of even drawing anything new upon the slate.

Even without a detailed knowledge of neuroscience, a critical reading of this article would alert the reader to fundamental problems.  In psychology it is called “internal consistency.”  This refers to a story having a logical progression that avoids contradictions.  The authors brought up the contradictions in order to dispel these arguments; long advanced by psychologists.  They tended to reframe the contradictions in an effort to prove their theory; rather breath new life into an old theory.  This is a perfectly normal error that bedevils all human thought.  Once humans formulate a goal, we will tend to gloss over the contradictions to obtain that goal.  It may be termed “messaging the data” to ensure that data proves the desired outcome.  Science is the bulwark protecting us from ourselves.  Always maintain a critical eye.  These authors have a bit of wool over theirs!

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