UC Health

Brain Health Navigator Program

UC Health, an academic medical center serving the Greater Cincinnati region, launched its Brain Health Navigator (BHN) program within primary care in partnership with the Memory Clinic and the Alzheimer’s Association. The program paired an RN navigator with an Alzheimer’s Association Social Worker (jointly hired with the Memory Clinic) to support a cohort of “Brain Health PCPs” trained to independently diagnose Alzheimer’s in primary care. A three-phase workflow spans pre-diagnosis workup, the Brain Health Assessment Visit, and post-diagnosis care management, which takes only 2 visits once the patient reports a complaint or the provider notices a decline during a routine visit or an annual wellness visit.

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Key Findings & Outcomes

Between July 2025 and February 2026, the BHN program generated 70 referrals across 5 PCPs, with 51% completing a Brain Health Assessment Visit and only 13% canceling or dropping from the queue. More than 95% of patients had the full pre-diagnosis workup completed before the Brain Health Assessment Visit, including biomarkers (pTau 217 or Precivity AD), MRI Icometrix, labs, and standardized social work and BHN assessments (i.e., I/ADL, NPIQ and STOP BANG, PSQI, and ACB respectively). Of patients completing the assessment, 47% were diagnosed with cognitive decline due to dementia, and 65% of those received a clear diagnosis of Alzheimer’s disease.

Clinical Impact

Time from BHN referral to diagnosis averaged 2.5 months, compared with 9 to 12 months when patients waited to be seen by the Memory Clinic. Forty-two percent of diagnosed patients remained in the care of their PCP and 36% were referred to memory specialists, optimizing capacity for complex cases and anti-amyloid therapy candidates. The program also embedded an Alzheimer’s Association Social Worker directly into primary care for the first time at UC Health.

Implementation Learnings

Successes included building a new clinical workflow from scratch, training Brain Health PCPs across the full diagnostic workup, and developing a comprehensive set of Epic tools (BHN referral order, dementia SmartSet, Clinical Dementia Rating (CDR) scale flowsheet, note templates, smartphrases, care plan template) that allow any trained nurse to execute the workflow. Use of nurse float pool was used during the hiring gap and forced detailed documentation of the workflow, producing highly transferable training materials. Challenges included a delay in recruiting a permanent BHN due to workforce shortage; a long timeframe to obtain alignment between compliance and revenue cycle teams on CMS billing regulations in hospital-based clinics; a learning curve for CDR rating; retooling PCP schedules to permit one-hour BH assessments; and inconsistent explanation of the BHN program, but this was addressed with new smartphrases and a patient-facing flyer.

Scaling & Sustainability

UC Health will continue refining the workflow through monthly debrief meetings with Brain Health PCPs and by summer 2026 plan to have a core cohort to support scaling to additional providers. To enable that scale, the team plans to develop CME-accredited educational videos for any UC Health PCP interested in learning to diagnose Alzheimer's, and to add Brain Health PCPs to the Epic neurology scheduling decision tree so they appear as available providers for brain health consults. Billing for BHN services is planned to launch later in 2026 once Epic billing team builds the workflow to automate the billing on both the professional and facility sides. Internal discussions are underway to complement billing revenue to fully sustain the BHN role.

Program Leaders

Rhonna Shatz, DO

Medical Director, Memory Care and Brain Health Clinic, UC Health

Katherine Schmidt, MD, MBA

Medical Director, Internal Medicine, UC Health

Anne Paul, MBA

Director of Learning Health System, UC Health

Wanda Leaman, RN

Brain Health Navigator, UC Health

Candace Burch, MGS, MSW, LSW

Geriatric Social Worker, Alzheimer’s Association of Greater Cincinnati and UC Health Memory Clinic

Key Partners

Alzheimer’s Association of Ohio
Eli Lilly (Brain Health PCP training grant)
Epic HQ (Episode of Care customization)