A Transdisciplinary Program for Care of Veterans With Neurocognitive Disorders.

Background: Veterans face specific risk factors for neurocognitive disorders. Providing them with comprehensive care for dementia and related neurocognitive disorders is a challenge as the population ages. There is a need for family-centered interventions, specialized expertise, and collaboration among clinicians and caregivers. The literature suggests that application of a transdisciplinary care model can address these needs and provide effective dementia care.

Observations: The Veterans Affairs Greater Los Angeles Healthcare System has employed existing expertise to create a conference-centered transdisciplinary model that responds to the US Department of Veterans Affairs directive for a dementia system of care. This model involves direct participation of behavioral neurology, geriatric psychiatry, geriatrics, neuropsychology, nursing, and social work. In this model, the social worker serves as a dementia care manager and, along with the nurse specialist, assures long-term management through follow-up and monitoring. Transdisciplinary interactions occur in a clinical case conference where each discipline contributes to the veteran's care. The team generates a final report on treating these veterans, the caregiver's needs, referral for psychosocial services, and plans for monitoring and follow-up.

Conclusions: This model could be a template of a program for implementing the Dementia System of Care across Veteran Affairs medical centers.