Models of Psychological Care in Nursing Homes and the Effects of Medicare Reimbursement Policies

So, as a long term care psychologist, I like to tell students and staff that I am really generally quite useless on my own in such a large, chaotic care environment like a long-term-care facility. Ironic, of course, because that’s the traditional model of provision in community nursing homes, right? The psychologist scurries in, sees patients in his caseload, he / she barely has time to talk to nursing staff, the psychologist scrawls some notes in the chart, and scurries out. This basically the traditional “collaborative care” consultancy model that I operated under when I worked my first year doing nursing home consulting post-licensure.

This traditional service delivery model (again, which is basically the rule in community skilled nursing facilities) is a direct result of the way we fund the services of psychologists in nursing homes – e.g., fee-for-service via Medicare, and overwhelmingly reimbursing for direct care services only (e.g., where the psychologist is interacting directly with the patient).

Moreover, this type of service delivery model – via economics – completely disincentivizes and discourages long-term-care psychologists from doing the most valuable kind of work they have in their arsenal, which is making close, collaborative partnerships with interprofessional care staff. Psychologists do all sorts of work with staff, formal and informal, which Medicare doesn’t (as far as I’m aware) reimburse for. In terms of informal, indirect services – we do “curbside consulting,” which is what I call those informal, friendly chats at nursing stations or in breakrooms where nurses, usually in the midst of chatting about unrelated issues (what they did for the weekend, etc.) they say “oh, by the way Doctor, can I talk to you about….” (insert behavior issue here).

In terms of the more formal work psychologists do? We do in-service trainings for nursing staff (I’ve taught classes for nursing CE credits, in fact). We are resources for mental health education for staff. One service which I find very enjoyable to deliver is the STAR-VA behavior management intervention, which deliberately makes sure to include Social Work, Recreation Therapy, physician staff, and nursing – because, bottom line, psychologists are generally fairly ineffective on their own. I attend care planning meetings where I assist and consult with nursing staff in developing care plans… and then there’s all the other stuff too! (Attending nursing reports, attending administrative meetings, etc etc etc).

So, what’s the moral of this post? At least as far as I can tell (because I don’t think Medicare’s approach to reimbursing psychologists for their work has changed much over the last few years since I worked as a private consultant), Medicare doesn’t pay psychologists do the most effective work they can do. Under Medicare, geropsychologists don’t tend to do their best work (unless they’re unusually creative and charitable, perhaps?).

I’m lucky though – I get a salary for what I do here at the VA (and I get paid reasonably well). So, I get paid just as much for seeing a patient for 1:1 therapy (which I do here and there) as I do for working with staff to brainstorm a difficult behavior management issue. I’ve seen how ineffective it is to operate as a Medicare-reimbursed psychologist in community nursing homes (it’s like sticking your fingers in the proverbial dyke, really), and I’ve also experienced first hand how much more effective I can be in my job as a collocated, salaried provider. Obviously you know what my preference is.

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