Program Profile

A Transdisciplinary Program for Care of Veterans With Neurocognitive Disorders

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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.


 

References

Dementia is a devastating condition resulting in major functional, emotional, and financial impact on patients, their caregivers, and families. Approximately 6.5 million Americans are living with Alzheimer disease (AD), the most common of many causes of dementia.1 The prevalence of AD could increase to 12.7 million Americans by 2050 as the population ages.1 Studies suggest that dementia, also known as major neurocognitive disorder, is common and underdiagnosed among US veterans, a population with a mean age of 65 years.2 During cognitive screening, memory impairment is present in approximately 20% of veterans aged ≥ 75 years who have not been diagnosed with a neurocognitive disorder.3 In addition, veterans might be particularly vulnerable to dementia at an earlier age than the general population because of vascular risk factors and traumatic brain injuries.4 These concerns highlight the need for effective dementia care programs at US Department of Veterans Affairs (VA) facilities.

The US health care system often does not adequately address the needs of patients with dementia and their caregivers.5 Dementia care requires specialized medical care among collaborating professionals and caregiver and psychosocial interventions and services. However, the US health care system is fragmented with different clinicians and services siloed into separate practices and most dementia care occurring in primary care settings.6 Primary care professionals (PCPs) often are uncomfortable diagnosing and managing dementia because of time constraints, lack of expertise and training, and inability to deal with the range of care needs.7 PCPs do not identify approximately 42% of their patients with dementia and, when recognized, do not adhere to dementia care guidelines and address caregiver needs.8-10 Research indicates that caregiver support improves dementia care by teaching behavioral management skills and caregiver coping strategies, allowing patients to stay at home and delay institutionalization.6,11,12 Clinicians underuse available resources and do not incorporate them in their patient care.10 These community services benefit patients and caregivers and significantly improve the overall quality of care.6

Memory clinics have emerged to address these deficiencies when managing dementia.13 The most effective memory clinics maximize the use of specialists with different expertise in dementia care, particularly integrated programs where disciplines function together rather than independently.1,5,14 Systematic reviews and meta-analyses have documented the effectiveness of collaborative care management programs.11,12,15 Integration of dementia care management is associated with earlier diagnosis and interventions, decreased functional and cognitive symptom severity, decreased or delayed institutionalization, improved quality of life for patients and caregivers, enhanced overall quality of care and cost-effectiveness, and better integration of community services.11,12,14-19 In these programs, designating a dementia care manager (DCM) as the patient’s advocate facilitates the integrated structure, increases the quality of care, helps caregivers, facilitates adherence to dementia practice guidelines, and prevents behavioral and psychological symptoms of dementia (BPSD).1,6,11,12,20,21

The best interprofessional model for dementia care might be the transdisciplinary model that includes a DCM. To meet the specific demands of dementia care, there must be a high level of interprofessional collaboration rather than multiple health care professionals (HCPs) delivering care in isolation—an approach that is time consuming and often difficult to implement.22 Whereas multidisciplinary care refers to delivery of parallel services and interdisciplinary care implies a joint formulation, transdisciplinary care aims to maximize integration of HCPs and their specific expertise and contributions through interactions and discussions that deliver focused input to the lead physician. The transdisciplinary model addresses needs that often are missed and can minimize disparities in the quality of dementia care.23 A DCM is an integral part of our program, facilitating understanding and implementation of the final care plan and providing long-term follow-up and care. We outline a conference-centered transdisciplinary dementia care model with a social worker as DCM (SW-DCM) at our VA medical center.

Program Description

In 2020, the VA Greater Los Angeles Healthcare System (VAGLAHS) in California established a multispecialty clinic dedicated to evaluation and treatment of veterans with memory and neurocognitive disorders and to provide support for their caregivers and families. With the agreement of leadership in mental health, neurology, and geriatrics services on the importance of collaboration for dementia care, the psychiatry and neurology services created a joint Memory and Neurobehavior Clinic, which completed its first 2 years of operation as a full-day program. In recent months, the clinic has scheduled 24 veterans per day, approximately 50% new evaluations and 50% follow-up patients, with wait times of < 2 months. There is a mean of 12 intake or lead physicians who could attend sessions in the morning, afternoon, or both. The general clinic flow consists of a 2-hour intake evaluation of new referrals by the lead physician followed by a clinic conference with transdisciplinary discussion. The DCM then follows up with the veteran/caregiver presenting a final care plan individualized to the veterans, caregivers, and families.

The Memory and Neurobehavior team includes behavioral neurologists, geriatric psychiatrists, neuropsychologists, geriatric fellows, advanced clinical nurses, and social workers who function as the DCM (Table 1).

In addition, regular meetings of the VAGLAHS dementia committee allow involvement with other professionals (physical, occupational, and speech therapists, an audiologist, an optometrist, and a dietitian) who routinely consult with veterans in the clinic. The Memory and Neurobehavior Clinic also includes trainees from different disciplines, fulfilling the VA’s role in educating future clinicians in managing neurocognitive disorders. These trainees are residents in neurology and psychiatry; fellows in behavioral neurology, geriatric psychiatry, and geriatric medicine; neuropsychology interns; medical students; and nurse practitioner students.

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