Posts tagged: 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!

Dementia-Clean or Dirty?

Is it possible to find someone with a “clean” dementia?  While this sounds like a misnomer, it is intended to describe people who suffer with a specific dementing pathology, and no other complications are known to exist.  It is a form of progressive cognitive deterioration that corresponds perfectly with its diagnostic category.  Only symptoms of this particular dementia are present, uncontaminated by other forms of physical or mental illness.  Hypothetically, such a “clean” dementia should readily conform to existing treatment protocols.  When a patient consults a neuropsychologist, they expect some sort of diagnosis with treatment recommendations, and not “well, it might be this, or it might be that.”  Families often vacillate between different factors to explain the changes in behavior and cognition, such that they expect definitive answers from a professional.  It is not unusual for the patient to become agitated when the doctor invariably, stereotypically, calls for more tests before they can arrive at a definitive diagnosis.  Why can’t we just do our job?

Here is where I frustrate my audience by reporting that diagnoses are rarely simple and clear cut, and that it’s typically a disservice to the patient to arrive at a quick and dirty diagnosis.  For example, a new patient came into the office yesterday with an old severe closed head injury.  This person exhibited classic signs of a severe traumatic brain injury.  Their personality and mental functioning were permanently altered in a way that is very consistent with the pathology of TBI that I was taught in school.  The easiest route is to dazzle the family with my knowledge of traumatic brain injury, make some behavioral and medication recommendations, and then sit back until they return in two weeks.  During the course of the interview with the family and patient, it became apparent that the patient endured a cerebral vascular accident immediately subsequent to the closed head injury.  Unfortunately, this is not an uncommon occurrence after severe closed head injury, though rare in mild to moderate injuries without a period of coma.  There are aspects of the patient’s balance and overall ambulation that would be uncommon in a “clean” closed head injury.  While the patient is walking in a functional manner, they often trip and fall into objects.  Weakness in one of their arms makes it difficult to perform tasks that require two hands.  Functional impairment from the stroke is as or more important than the impairment secondary to the closed head injury.  Formulating recommendations based on one or the other diagnosis would be unsafe and unwise.  Only by thinking in terms of the patient’s holistic or overall functioning would I be able to make their life safer and more stimulating.  Stated another way, diagnoses are typically less important than the obvious difficulties the patient confronts in their environment every day.

How is a physician able to prescribe the correct medication without the correct diagnosis?  Since the Food and Drug Administration does not allow direct comparison between drugs, physicians cannot be confident that they are using the single best medication for a given illness.  While certain medications are believed by professionals to be better for organic conditions than psychiatric conditions, there is only modest support in the research for using one medication over the other.  The best clinicians tend to prescribe by side-effect; that is there are many medications that claim to do the same thing, but the risk of unwanted and possibly deleterious effects of any given medication are uppermost in their mind.  For example, the physician is weighing the benefit of two tranquilizers.  The med they typically prescribe for most neurologically intact patients causes memory and attentional impairments, and the other tranquilizer is known to have few cognitive side-effects, but may cause trouble with ambulation.  Most of us, physician or not, would avoid using the first medication in someone recovering from a closed head injury, and avoid the second for someone recovering from a stroke or movement disorder.  While this appears to make good sense, and even smacks of common sense, one has to keep in mind that common sense is anything but common.
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The common sense approach to treatment of damage to the central nervous system is driven by symptoms and their expression in the patient’s unique environment.  A diagnosis helps alleviate the anxiety of family members and the insurance industry, but in isolation, does little to assist the patient.  Medications prescribed for their main effect rather than by their side-effect may help in one area and cause problems in another, rendering little to no net gain for the patient.  Clinicians that need to find neat categories and rapid solutions will please the family shopping for confidence more that the family looking for real gains.  Lastly, even the best of treatment protocols needs adjustment.  People change over time, and the cognitively impaired are no exception.  Any intervention that has positive results for a year or more should be considered a success-even if there is a subsequent decline.  Consider periodic adjustments to behavioral and medication protocols to be necessary and expected.

To answer the initial question, it is rare, indeed, to find a “clean” dementia.  Even if the initial stages of the dementia are uncomplicated and according to protocol, the illness rarely remains so orderly for its entire course.  Patients and family members often gain confidence from hurried and decisive experts; tending to view their curt behavior as a sign of social importance.  A clinician who is unsure and vacillating about treatment options exudes less confidence to others, but may ultimately be the most concerned and helpful.  Please leave comments regarding this article by clicking on “comments” immediately below this post.