Home
About DAC-SP
Early Detection Blueprint
Case Studies
Grant Recipients
Resource Index
US Fellowship RFI
Contact
Home
About DAC-SP
Early Detection Blueprint
Case Studies
Grant Recipients
Resource Index
US Fellowship RFI
Contact
USA - New Hampshire
Dartmouth Health, an academic medical center serving rural New Hampshire, Maine, and Vermont, is located in the region with the highest per capita senior population in the United States. Dartmouth Health launched its Brain Health Navigator (BHN) program within Geriatric Psychiatry and partners with the Department of General Internal Medicine and Family Medicine. The program follows a flexible clinical workflow: Primary Care Providers refer patients with cognitive changes to the BHN program, where the Brain Health Provider (APRN) and Brain Health Navigator (RN) conduct cognitive and functional screening, order appropriate diagnostics (PET, biomarkers, lumbar puncture, labs, genetics), and connect patients with neuropsychology for abridged testing focused on neurocognitive phenotyping. During follow-up, the Brain Health Navigator recommends treatment strategies and diagnostic orders, in collaboration with the PCP, supporting early diagnostic and treatment management.
Over the first four months, the pilot generated 19 referrals from two PCP champions, with 8 patients seen by the Brain Health Provider and 4 completing neuropsychological testing. The program reduced wait times and appointment duration for neuro psych testing and introduced a standardized early-detection pathway. PCP champions began ordering labs for reversible causes at referral, freeing the Brain Health Provider to focus on advanced diagnostics.
The model reduced cognitive care silos across primary care, geriatrics, geriatric psychiatry, and neurology, establishing the first standardized cognitive care referral pathway at Heater Road Clinic and General Internal Medicine with Epic-embedded decision support. Financial viability was demonstrated via 99483 and PCM codes, and the Department of Psychiatry committed dedicated faculty time beyond the BHN program. A novel AI Patient Actor training tool was developed with Geisel School of Medicine at Dartmouth for scalable, standardized BHN onboarding.
Successes included strong executive and clinical champion support, Epic referral sets and cognitive care smartforms built with Clinical Informatics, as well as biweekly bridge meetings between primary and specialty care for ongoing training and case consultation. Challenges included scheduling delays across BHN and neuropsychology slots, and PCP uncertainty about ordering and communicating advanced diagnostic results to patients despite workflow support.
The BHN program is continuing under departmental commitment, with referrals expanded to all Heater Road providers and plans are underway for system-wide dissemination. Financial sustainability has been established through routine use of the cognitive care plan appointment and PCM billing codes. Additionally, strong patient interest combined with alignment to system-wide strategic priorities has secured departmental buy-in. Building on this foundation, the BHN program aims to accept system-wide referrals as well as continuing to develop the interdepartmental brain health team.
KB
Karen Blackmon, PhD
Neuropsychologist, Dartmouth Health
CC
Corie Crane, DNP, APRN, PMHNP-BC
Geriatric Psychiatry, Dartmouth Health
DM
Daniel Moran, DNP, APRN
General Internal Medicine, Dartmouth Health
DV
Dax Volle, MD
Geriatric Psychiatry, Dartmouth Health
KG
Krista Gould, APRN
Heater Road Family Medicine, Dartmouth Health