A cognitive assessment should be completed annually for all patients 65 and older with a patient visit who have not previously been diagnosed with dementia.

Work with your clinic staff to determine the best ways to integrate the screening process into existing workflows at the very minimum we recommend the following: 

1. Conduct the CHA with patients over 65 without a previous dementia diagnosis.  
2. Identify eligible patients within 1 month of an appointment.  
3. Utilize your EHR whenever possible to identify eligible patients.   
4. The specific assessments used are up to the discretion of the clinic, however Dementia Care Aware recommends the Mini-cog, GP-Cog and/or AD8 and the ADL/IADL Checklist. The full cognitive health assessment as recommended by Dementia Care Aware can be found here. 
5. Use Dementia Care Aware recommended CHA and make modifications to the screenings based on the patients’ needs. 

Ask your team these questions when establishing the patient identification and CHA process: 

• What role (who) is responsible and/or what system (EHR) will be used to identify patients for screening? 
• What triggers or alerts are in place or need to be developed to notify staff that a CHA is recommended for their patient?  
• When will the CHA be administered (prior to or during PCP appointment)? 
• Where will the CHA be administered, how and by whom (e.g., in patient room by a physician, over the phone by nurse practitioner)? 
• Which screening tools will be used? (Recommend: Mini-cog, GP cog, ADL/IADL, AD-8) 
• Are there modifications or supplemental screens required for special patient populations? 

Interpretation and disclosure of cognitive screening results is a pivotal step in the CHA process. It lays the path for all following cognitive health conversations and if eligible for reimbursement, must be completed by a clinician. Regardless of whomever conducts the assessment and/or councils the patient, the results must be interpreted by an authorized clinician. Therefore, when building your process, you and your team must consider the timing (i.e., workflow) and roles (e.g., MA, NP, MD) that will be conducting the CHA relative to interpretation and disclosure. When disclosing and counseling patients and their care partners, use an intentionally hopeful, holistic, and strengths-based approach as summarized below. See “Best Practices for Interpreting and Disclosing Results” for further recommendations. 

Disclosure Best Practices 

Ask your team these questions when establishing the interpretation, disclosure, and documentation process: 

• Who will interpret the CHA results? 
• When and where will the CHA be interpreted (prior to, during, or after the MD/patient conversation, in the presence of the patient, etc.)? 
• Who will disclose the CHA results to the patient and/or their support person, and what approach will be used during disclosure? 
• How and where will results and disclosure be documented in the patient record (narrative summary note, part of the assessment comments, checkbox on a flowsheet, etc,)? 

The EHR serves as the existing central database and documentation source for healthcare professionals and serves to streamline data for quality care and improvement efforts. Therefore, it is recommended that the EHR be utilized for documenting the cognitive screening process. Dementia Care Aware recognizes that EHR system use varies in type and capacity of use across health care organizations, and that EHR changes and updates are complex and often requires support from a variety of stakeholders.   

Dementia Care Aware has developed resources for integrating the cognitive health assessment into an EHR including tipsheets and how-to guides for making a case to leadership for EHR integration, tools for standardizing documentation across users, and recommended fields for reporting. Click here to access more EHR related resources. 

Ask your team these questions when establishing the documentation and billing process: 

• What EHR modifications are required to implement documentation of cognitive health assessments? (e.g., smart/dot phrases, etc.) 
• Who is the tech-savvy EHR champion advocating for implementation support? 
• What approvals are necessary for finalizing proposed EHR changes? 
• Who will be involved in creating EHR changes and how will needs be communicated to them for builds? 
• What is the expected timeframe for implementing EHR changes? 
• What level of EHR access is needed for the roles involved in patient identification, screening, and documentation? 
• Where in the EHR will the screening and results be documented (narrative summary, field within assessment page, etc.)?  
• How will appropriate billing codes be linked to CHA screens for tracking screened and/or reimbursement? 
• What needs to be done to prepare and align the EHR for reporting? 

Brain health planning refers to support and interventions provided to patients and their care partners that support whole person wellness. Planning includes clinical interventions such as hearing and vision testing, labs, imaging, and medication management, as well as connection to individualized legal, community, and psychosocial supports. The next steps after a screen are summarized below. Click here to access the full workup guide and timeline resource. 

Healthcare teams should conduct these 6 next steps immediately following positive screen (During the screening visit or within 3 months of the screen: 

1. Confirm identified primary care partner.  
2. Obtain a history of any existing psychiatric diagnosis. 
3. Consider labs for: STD’s (RPR), HIV, thyroid conditions (TSH), and B12 deficiency.
4. Screen for other conditions: Depression (PHQ9, GAD-7), alcohol abuse or misuse (AUDIT-C, SMAST-G), hearing, vision, and loneliness. 
5. Identify concerning characteristics:  < 60 years old, focal neurologic finding, gait disturbance, new onset of incontinence, recent head trauma, rapid decline, use of anticoagulants, history of non-skin malignancy, and HIV.
6. Consider brain imaging (noncontrast MRI, CT). 

Maintaining brain health is a lifelong journey regardless of age. That is why discuss the following 6 things should be discussed with all patients within the first year of the screen regardless of their screening results: 

1. Recommendations and referrals to specialists and community resources, 
2. Body movement and daily exercise plan, 
3. Routine medication review including supplements and deprescribing as able, 
4. Meaningful mental activity tailored to patient’s ability and interests, 
5. Socialization and opportunities in the community to engage with others, 
6. Routine review of physical health problems through an annual wellness visit that includes hearing, vision, and depression screening. 

Ask your team members the following questions when establishing brain health planning guidelines: 

• At what point in the care process does brain health planning occur (during visit where assessment was conducted, after visit, etc.)? 
• Who will receive resources (patient, care partner, etc.), and who will provide these resources (e.g., MD, MA, Nurse, SW)? 
• What elements and recommendations will be included in the initial brain health care plan? 
• What elements and recommendations will be included in subsequent visits for follow-up? 
• How will information be presented/provided to patients and care partners (e.g., in person education, physical tip sheets, referral to social work)? 
• Where in the patient record will brain health planning be documented?