Posts tagged: nursing home

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!

When to Seek a Nursing Home

Dr. Holzmacher's Business LogoWhen is it the correct time to seek the assistance of a nursing home?  This is a monumental decision.   An initial hurdle is the public perception of nursing homes.  It is the place to go when one is ready to die.  This remains true for some, but much less than even twenty years ago.  Over half the patients admitted to Florida nursing homes leave in a better condition than when they were admitted.  Increasingly, nursing homes are fulfilling the duties of hospitals.  Most rehabilitation is now conducted in nursing homes, rather than hospitals and free standing rehab centers.  Rehabilitation is a general term for physical, occupational and speech therapy services.  In the state of Florida it would be fair to say that emergencies are evaluated at the hospital, but most of the long-term treatment occurs in the nursing home.

In the most general terms, seek nursing home treatment for a loved one when you are no longer able to care for them at home.  This statement sounds a bit obvious, but it is not obvious in practice.  Most people in the United States wait too long before seeking treatment for a loved one with Alzheimer’s Disease.  I will repeat that statement.  Most people wait too long for nursing home treatment.  This fly’s in the face of world opinion that American’s are quick to institutionalize the elderly.  Over the last twenty years, I have treated hundreds of patients whose only crime was to care for a demented loved one until they were physically and emotionally exhausted.  I have witnessed dozens of families form three shifts to care for an elderly parent twenty four hours a day, seven days a week.

An especially poignant example is a family aftercare group.  A woman tearfully described the guilt she experienced placing her mother in the nursing home.  She had cared for her severely demented mother for nearly twenty years; seriously impacting her marriage and career.  Like so many, she found herself in the unpleasant and awkward position of changing her mother’s dirty diapers.  At the time of her mother’s admission, she was over one hundred years old, and required total care for bathing, dressing and toileting.  Her tears became torrential when others in the group reflected the depth of her devotion and sacrifice.  The situation was not unusual, it was the support she received from peers of her own age that etched the story into memory.

Another misconception is that demented elderly patients will decline rapidly in the nursing home.  It is may be awkward for family members to admit their loved one has mentally and physically improved in the nursing home.  It is easier to coordinate physician care in the nursing home.  On an outpatient basis, physicians rarely have a coordinated picture of the total clinical situation.  Said another way, Dr. A may unfortunately not be aware of what Dr. B has prescribed.  Dr. B may not be aware there is a Dr. A. .  In the nursing home, there is a master medication record, and this record is often reviewed by pharmacists to catch possible drug interactions-or just plain errors.  The nearly universal lack of coordinated outpatient care leads to many preventable iatrogenic hospital and nursing home admissions.  A potentially positive aspect of nursing home care is the increased socialization.  So many widowed and single elderly become extremely isolated, and this lack of socialization may be destructive to their mental and emotional functioning.  Family members are often surprised to the degree their loved one’s spirits have brightened in the nursing home.

A general rule of caring for a loved one is to not exhaust yourself in the process.  Once exhausted, a caretaker is largely worthless to the patient and themselves.  You will not be doing anyone a favor by working yourself to death.  Do not be deceived that nursing home placement is a sign of personal failure, or that keeping a loved one in their home will slow the disease.  Consider adult day care if you are becoming exhausted caring for a person with a progressive dementia.  Once the loved one experiences falls, becomes aggressive or escapes from the home, have them evaluated as soon as possible.  Please visit local nursing homes and develop a relationship with the ones that appear most promising.  Do not wait to evaluate institutions until the patient has an emergency-typically a fall.  Please listen to close others who tell you to lighten the workload.  We only know ourselves through the eyes of others.  A happy nursing home visitor will likely do more for the patient’s spirits than a depleted caretaker cleaning another diaper.

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