Long-Term Care 

The vast majority of the over 40 million older adults in the United States live independently in the community (Federal Interagency Forum on Aging-Related Statistics, 2012). Working with older adults requires specialized competencies and skills (c.f. Molinari, 2011); however, the long-term care (LTC) environment is often home to a unique subset of the older adult population. These individuals are often differentiated from their community-dwelling counterparts based on their advanced age, disability status, and fewer resources for living independently (Hill, Thorn, Bowling, & Morrison, 2002). Working with such a population poses a unique challenge for mental health providers, as various medical, familial, and societal factors must be simultaneously considered. Psychologists working in the LTC environment may be consulted for a variety of issues, such as health and behavioral concerns, end-of-life issues, or mood disorders. Regardless of the intervention needed, collaborating with multiple professionals is a vital skill. The resources outlined below offer guidance for psychological practice in a LTC setting and highlight considerations and methods for interventions of commonly found issues in the LTC environment.

Clinical Role

Upon referral, patients should undergo a complete diagnostic interview. Testing, including measures of cognitive, psychological, and neuropsychological functioning, may or may not be part of the initial clinical workup. However, in view of the complex presentation of symptoms, the interaction of medical and psychological conditions, and the fact that a patient’s self-report often minimizes true underlying impairments in older adults, cognitive and psychological test measures are strongly recommended. Testing helps to document the presence and severity of psychological disturbances, decision making capacity, attitudes toward recovery, helps with treatment planning, and establishes a baseline to measure future progress or decline.

Individual, group, and family psychotherapy are all effective treatment modalities with this population. Many of the traditional professional services provided by psychologists in outpatient, residential and long term care settings address adjustment disorders. Long term care admission and placement can produce psychological disorders due to a loss of independent functioning, separation from one’s home and family, and becoming dependent on caregivers. Depression and generalized anxiety symptoms are frequently in the clinical picture, and manifested typically by withdrawal and isolation, eating and sleeping problems, non-adherence to treatment plans, and disruptive behaviors. Also, behavior problems often accompany the mental decline that accompanies dementia. The theme of death and dying must be included in the purview of the consulting psychologist, as well as counseling and support for the patient’s family, and psychoeducation on a variety of clinical issues.

If a patient is inappropriate for psychotherapy services, developing and implementing behavioral strategies (beyond the initial assessment and written plan) without patient interaction and without engagement in a psychotherapeutic process is not billable.  Further, conferencing with staff about behavioral interventions also is not billable.

The health and behavior CPT codes allow psychologists to treat patients who do not have a psychiatric disorder or diagnosis. Assessment and interventions are based on the medical diagnosis, the co-morbid or underlying psychological factors affecting or impacted by the medical conditions, and problems in coping with or managing the medical condition. These procedures are a valuable alternative to traditional assessment and psychotherapy codes, as they allow the practitioner to capture necessary services related to a patient’s physical health, adherence to medical treatment, coping skills, health-promoting behaviors, and health-risk behaviors.

Most insurance plans, including Medicare, do not cover staff consultation, case conferences, supervision of behavioral interventions, or staff training.

Documenting Services

When services are billed to Medicare, they must meet the criteria for medical necessity. Each Medicare Administrative Carrier publishes its own policies for every specialty, stipulating what services and procedures are authorized, what criteria must be met for each billed procedure, and what services are excluded from coverage. For behavioral health services, all initial clinical interviews, psychological testing, and ongoing progress notes must contain certain elements in order to meet the rigors of medical necessity. Behavioral health professionals are also required to communicate regularly with the patient’s attending physician, a practice that is easily complied with in nursing homes, but extra steps must be taken in residential and assisted living facilities because visits by the attending physician and chart reviews are not routine. More information is available on the GeroCentral Documentation page.

Contracting

Technically, the requirement for a written contractual arrangement lies with the agency or facility where a psychologist might work. The facility often must document to outside entities (e.g., State Department of Health) when a behavioral health practitioner is consulting at that location. Otherwise, a practitioner may see and bill these patients privately in that setting without a formal, written agreement. Nonetheless, it is good practice to outline in writing what the practitioner and what the facility agrees to, including access to medical and financial records of patients referred, and patients’ right to privacy and confidentiality (and exceptions to these rights). Arrangements for paid consultation by the practitioner may also be included (e.g., staff training, participating in treatment team meetings or family councils, or working with unfunded patients).

Collaboration

Ideally, the mental health practitioner is perceived as a member of the interdisciplinary treatment team.  The more that the team members confer with each other and discuss treatment plans based on the patient’s unique strengths and weaknesses, as well as the constellation of medical, social, and psychological problems that are present, the more the patient will gain from this collaborative interaction.  Attendance at nurses’ care plan meetings and other events (e.g., psychotropic management) fosters an integrated care model, even though this time is not billable to or reimbursable by health insurance. Under separate agreement with the care facility, however, the behavioral health consultant may bill for his or her time at these staff meetings.

Consultation in any long term care setting requires the psychology practitioner to communicate in ways that the medical team understands. The team members want answers to quickly diagnose and fix problems. They need concise information and updates.  Thus, this is part of our changing role as we become part of this interdisciplinary team and communicate more effectively with medical professionals (see Hamberger, 1999).

Staff in-services are always highly desired in long term care settings, and the most sought after topics include managing problem behaviors, communicating with confused residents, stress management, ethics and end of life issues, and family interactions.

Written by Joseph M. Casciani, PhD

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