Name
Advancing Integrated Cognitive Care: Expanding an Interdisciplinary Workflow for Primary Care Dementia Diagnosis and Support
Description

Primary care teams are uniquely positioned to identify and manage dementia and cognitive concerns, yet fragmented workflows, unclear roles, and limited interdisciplinary diagnostic support often impede timely and accurate evaluation. This presentation outlines the development and regional implementation of an integrated cognitive screening and diagnostic support workflow designed to enhance primary care’s ability to assess cognitive changes, support earlier diagnosis, and initiate appropriate treatment and care planning. Through a multidisciplinary, collaborative design process, the workflow standardizes handoffs, clarifies team roles, and embeds cognitive assessment tasks into real world clinic operations. Attendees will learn how behavioral health providers, nurses, and PCPs coordinate screening, functional assessment, and preliminary interpretation to streamline cognitive evaluation. The session provides actionable design principles and rollout strategies that health systems can adapt to strengthen cognitive care within primary care settings.

Speakers
Lindsay Moore, PhD
Elisa Rudd, PsyD
Co-Authors
Katie McCulloch, PhD Laura Braunstein, PsyD Rupinder Heer, PhD Elisa Rudd, PsyD TysonPayne, PsyD
Content Level
Intermediate
Tags
Geriatrics, Primary Care Behavioral Health Model, Quality improvement programs
Session Type
Concurrent
Objective 1
Describe an interdisciplinary, primary care–based approach to cognitive screening and diagnostic support that extends beyond single tool screening.
Objective 2
Identify the roles of multiple disciplines (MA, RN, PCP, Behavioral Health, Care Management, and Patient Care Coordination) in supporting early diagnosis and management of cognitive concerns.
Objective 3
Apply key workflow design principles that balance standardization with clinic level flexibility.
Content Reference 1

Hilsabeck, R. C., Perry, W., Lacritz, L., Arnett, P. A., Shah, R. C., Borson, S., Galvin, J. E., Roaten, K., Daven, M., Hwang, U., Ivey, L., Joshi, P., Parish, A. L., Wood, J., Woodhouse, J., Tsai, J., Sorweid, M., & Subramanian, U. (2024). Improving early detection of cognitive impairment in older adults in primary care clinics: Recommendations from an interdisciplinary geriatrics summit. The Annals of Family Medicine, 22(6), 543–549. https://doi.org/10.1370/afm.3174

Content Reference 2

O’Brien, K.S., Harkins, K., Peifer, M. et al. Designing an intervention to improve cognitive evaluations in primary care. Implement Sci Commun 6, 9 (2025). https://doi.org/10.1186/s43058-025-00693-1

Content Reference 3

Valcour, V. G., Masaki, K. H., Curb, J. D., & Blanchette, P. L. (2000). The detection of dementia in the primary care setting. Archives of Internal Medicine, 160(19), 2964–2968. https://doi.org/10.1001/archinte.160.19.2964