Sharp Rees-Stealy

Brain Health Navigator Program

Sharp Rees-Stealy Medical Group, an integrated medical group based in San Diego, CA, launched its Brain Health Navigator (BHN) program within its Population Health Department with the ambitious long-term goal to screen 100% of Medicare Annual Wellness Visit (AWV) patients. The program deployed a medical social worker (MSW) navigator embedded in the Population Health team, working alongside Community Health Workers (CHWs) who conduct pre-screenings and initiating outreach to patients. The program utilized a simple pre-visit questionnaire to trigger referrals, with all findings documented in Epic, and employed biweekly team meetings to serve as iterative quality improvement sessions.

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Key Findings & Outcomes

In the early implementation phase, the program reviewed 88 patient referrals and completed 28 assessments, with 5 patients showing mild cognitive changes and 3 patients engaged into behavioral health case management. While the low positive screening rate reflected referral criteria misalignment that continued to be refined throughout the program, all assessed patients were scheduled for 6-month follow-up, establishing a longitudinal model. Neurology became engaged as a clinical partner, and the program demonstrated early success despite being in its implementation phase.

Clinical Impact

The program established a scalable population health infrastructure positioned for future Medicare AWV screening, with targets of 200+ referrals planned for 2026. Sharp demonstrated the value of embedding existing staff and workflows to facilitate referrals, conduct cognitive screens, and coordinate care. While billing had not yet been initiated at the time of program completion, the phased approach prioritized quality of care and operational readiness while laying the groundwork for future reimbursement strategies.

Implementation Learnings

Key successes included leveraging the MSW's existing familiarity with clinic physicians, which accelerated trust and adoption across the system. The CHW pre-screening model provided an important population-level touchpoint, and strong interdepartmental collaboration with Population Health leadership enabled smooth integration. Primary challenges centered on identifying the right patient population, requiring refinement of referral criteria. Sharp is also refining the pre-screening tool and expanding physician efforts to improve referral quality and strengthen collaboration between clinical teams.

Scaling & Sustainability

Sharp Rees-Stealy established regular Brain Health Navigation team meetings with key stakeholders across departments to align efforts and leverage best practices from other health systems developing similar models. The BHN team is working with the Neurology department to demonstrate how early identification and intervention for cognitive decline can improve patient outcomes while reducing healthcare costs through proactive care planning, reduced emergency department utilization, and delayed institutionalization. By building a collaborative framework focused on measurable outcomes, Sharp aims to strengthen the business case for sustaining and scaling the BHN role as an integral part of their care delivery model.

Program Leaders

John Clark, MD, PhD

Chief Population Health Officer, Sharp Rees-Stealy

Janet Appel, MSN, RN

Director of Population Health, Sharp Rees-Stealy

Scott Heimer

Project Manager, Sharp Rees-Stealy

Sarah Ferrara

Medical Social Worker, Sharp Rees-Stealy