Category: Vascular Dementia

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!

Political Weight

Business Logo for Psychological and Neuropsychological IssuesFew people are desirous of additional body weight.  Few people consider their appearance to be embellished by additional body weight.  It has come to be proverbial, the billions spent on weight loss programs and systems.  Even so called medical TV programs rarely speak of medicine as they do weight loss.  It is a hook that latches onto viewers.  In order for the hook to be effective, it must be on the minds of many people.  These medically oriented programs rarely advance scientifically proven behavioral weight loss techniques.  In its stead, dietary and medicinal tricks are employed to tout rapid weight loss.  Shills are often employed to model the incredible success that remains outside the grasp of the audience.  The feared net effect is to cheapen the reputation of medical practice and increase the frustration of the target audience.

Body image and bodily health are the two important components of weight loss.  These components reflect the psychological and medical issues surrounding weight gain or loss.  In terms of body image, not everyone wants to be thinner.  Many people perceive obese partners to be particularly attractive; as evidenced by web sites thriving on the erotic portrayal of plump sexual athletes.  It is suspected that such couples are not in search of weight loss programs.  In fact, weight loss experienced by either partner may cause discord in the relationship.  It is curious that this type of couple does not generate web sites dedicated to gaining sexy weight.  Gaining weight appears to be effortless.  Gaining weight does not appear to require third party motivation.

Despite couples that revel in their sexy obesity, most couples do not seek to gain weight.  The majority does not perceive obesity to be attractive in others, nor are they pleased by weight gain reflected in the mirror.  The body image of the majority tends to favor weight loss and an athletic build.  While this is true of the current situation, different periods in history do not necessarily share the modern worship of thin.  For example, the famous Rubenesque woman painted in the 17th century.  These plump women were considered the epitome of attractiveness.  To be called Rubenesque was, in the distant past, quite a compliment.  Today, it has come to be a benign term for fat.  If we retreat further into the past, Roman women were the first group known to engage in resistance exercises!  The Roman and Greek ideal was as now; an athletic physique maintained by either sex.  An ideal body image tends to change over time, but apparently it is not in a rush.  It is probably better not to wait until your less than athletic physique comes back into style.

The medical issues surrounding obesity may be as complex as the psychological.  It has long been medical dogma that body weight exceeding the average is axiomatically bad for one’s long-term health.  Public health research has revealed that the mildly obese tend to survive hospital stays significantly more than those of average weight.  The survival rate of the mildly obese, compared with those who are of less than average body weight, is especially striking.  Particular races of people tend to have bulkier physiques when compared to other races with the same percentage of body fat.  Metabolism is certain to play a role, but so does a person’s level of fidgeting.  Thin people tend to engage in unconscious fidgeting movements more than those who tend to be overweight.  It appears that fidgeting burns a surprising amount of calories.  The lack of movement in the the severely obese is a contributing factor to what is termed the “metabolic syndrome” of obesity.  This syndrome is comprised of medical factors related to coronary artery disease, stroke, and insulin-dependent diabetes.  Fortunately, this medical penalty for obesity is much less common in the moderate and mildly obese; the ones that tend to leave the hospital by the front door.

In terms of treatment, successful weight loss interventions should begin in childhood.  It is less an intervention than modeling behaviors that promote a healthy diet and exercise.  As with any childhood behavioral program, the full participation of the family is critical.  Children not only model what their parents do, but are quick to imitate a favored older brother or sister.  The focus should not be on what foods are to be avoided as increasing the consumption of fruits and vegetables.  School programs that decrease the availability of sugary foods and beverages has made a significant difference in several longitudinal studies.  Severely obese children have been the exception.  There have been no successful behavioral weight interventions with this unfortunate subgroup.

It is not only what foods are best to consume, it is also important to consider how they are prepared.  For example, a very successful behavioral intervention is somewhat counter-intuitive.  Having the child or adult participate in the preparation of the meal tends to reduce impulsive eating.  A rough analogy is rolling a cigarette as opposed to buying a pack ready made.  The additional work and attention to quality tends to lower the overall quantity.  Similarly, the mindset regarding exercise is very important to a successful program.  Profuse sweating and possible ridicule is not very motivating, unless one is attempting to increase their aversion to exercise.  It is important to start gradually and focus on feeling better physically, than evaluating oneself by how many pounds are lost.  An exercise program will be less aversive if the goal is to breath and walk with greater ease, than if improvement is measured by one’s attractiveness.  A focus on pounds and appearance is usually problematic, since no one loses weight fast enough, or suddenly becomes enamored with their appearance.  If a person employs these behavioral techniques in a consistent fashion, an attractive stranger is sure to make their appearance in the mirror.

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