Brain Health Navigators: Optimizing the Alzheimer Disease Care Pathway Through Boundary-Spanning Roles

Alzheimer disease (AD) represents a pervasive global health crisis with devastating disease burden. More than 7 million Americans aged >65 years have AD, and the condition affects countless families worldwide. For people with AD and their care providers, early and accurate diagnosis is crucial as it enables access to emerging disease-modifying therapies that are most effective in the earliest stages, allows future planning, facilitates enrollment in clinical trials, and opens pathways to lifestyle interventions that may slow disease progression. Up to 45% of dementia cases can be prevented or delayed through modification of risk factors,¹ and lifestyle practices, such as regular exercise, brain-healthy diets, cognitive activities, and heart health management, have shown promise in improving cognitive function in early AD.^2,3

Despite these opportunities, rates of timely diagnosis remain low. It is estimated that only ~8% of people with AD receive a diagnosis at the earliest stages of cognitive impairment.^4,5 A key challenge for clinicians is delayed diagnosis and inefficient pathways that fail to identify and triage patients appropriately.

Primary care providers are vital gatekeepers for the early detection of cognitive impairment and are often an individual’s first point of contact within the health care system.⁶ However, they face substantial obstacles, including limited training on screening and diagnosis, low confidence in differential diagnosis, and lack of standardized cognitive assessments.^7,8 These challenges are compounded by time constraints, fragmented diagnostic and referral pathways, and limited access to resources, such as specialists, neuroimaging, and biomarker testing.^7,9,10

Meanwhile, many individuals with cognitive concerns do not follow up on specialist referrals or miss scheduled appointments, and health care systems struggle to track their outcomes. Individuals frequently have difficulty navigating primary care and specialist visits as well as accessing community resources, and many never learn about options such as lifestyle interventions, legal and financial planning, caregiver support programs, and clinical trial opportunities. Fragmented care leads to increased emergency department visits, avoidable hospitalizations, and higher overall health care costs.¹¹ Numerous local support programs exist that could help families, but many doctors are not aware of these available resources. Together, these challenges highlight a clear need for boundary-spanning roles that can help individuals and health care systems navigate the complex landscape of AD diagnosis and care.

Development of the Brain Health Navigator Model

In January 2025, the Davos Alzheimer’s Collaborative (DAC), a pioneering worldwide initiative with the goal to accelerate innovation and deliver solutions to improve brain health,¹² launched its Brain Health Navigator (BHN) program. The BHN program, led by the DAC Healthcare System Preparedness (DAC-SP) team, provides resources for people with AD and their health care providers at 6 pilot sites across the United States.

The program addresses a fundamental challenge: health care systems require multiple stakeholders to rapidly and efficiently coordinate and triage individuals to the right care at the right time. Previous implementation studies by DAC-SP identified navigation support as vital for improving access to a diagnosis for people with AD as well as for providing resources to enable needed changes in clinical workflows.^10,13

DAC-SP partnered with 6 US health care systems with real-world experience: Dartmouth Health (Lebanon, NH); Memorial Healthcare (Owosso, MI); Norton Healthcare (Louisville, KY); Sharp Rees-Stealy Medical Group (San Diego, CA); UC Health (Cincinnati, OH); and Keck Medical Center of the University of Southern California (Los Angeles, CA). Sites were selected on the basis of strong program leadership, contemporary experience with new diagnostic tools and therapies, diverse populations, implementation readiness, and potential for sustainability beyond the grant period.

Pilot sites worked together as part of a community of practice, developing materials and best practices for long-term sustainability and expansion of the BHN model without external funding. Each site developed navigation programs focusing on addressing care gaps, creating value for people with AD and their caregivers, allowing practice flexibility, and identifying sustainable funding streams. The DAC-SP team provided coordination, technical assistance, and resources, and each site adapted the core model to local needs.

Who Can Serve as a BHN

BHNs can come from various health care backgrounds, and pilot sites have successfully employed social workers, medical assistants, registered nurses, and advanced practice providers, including nurse practitioners, in this role. The level of clinical responsibility and scope of practice varies on the basis of the navigator’s personal training and licensure, as well as institutional processes and established workflows. For example, advanced practice registered nurses may have the authorization to order blood tests, laboratory studies, and imaging, whereas medical assistants work under the supervision of a clinician and provide administrative and patient support. This flexibility in staffing allows health care systems to adapt the BHN role to their organizational processes and existing workflows.

How the BHN Model Works

Whereas each site customizes the model to fit its unique local setting, several core elements remain consistent across implementation. BHNs serve as connectors to bridge gaps among primary care, specialty care, and community services, ensuring that individuals with cognitive concerns move efficiently and continuously through the diagnostic process. The BHN model could be applied to individuals with any type of dementia, although some focus more on AD owing to the availability of diagnostic tests and treatment options.

Referral and Intake

Primary care physicians, general neurologists, and other clinicians can refer individuals with memory or cognitive concerns to the BHN. Referral criteria are determined by the site and may include the following:

• Subjective cognitive complaints from the patient or the patient’s family
• Observed changes in memory
• Abnormal cognitive screening results
• Concerns about functional decline in daily activities or behavior changes
• Need for care coordination for individuals with diagnosed mild cognitive impairment

Providers initiate referrals on the basis of their local processes and take into consideration the needs and concerns of the patient and the patient’s family. Cases that may require more urgent evaluation (eg, rapidly progressive symptoms, safety concerns) can be flagged for priority scheduling and the BHN may contact a provider within the memory center directly, if appropriate.

The navigator is the central point of coordination, gathering background information and initiating structured assessments. The BHN can review the referral, contact the patient or the patient’s family to schedule an initial assessment, and start the process of collecting relevant medical history to determine the next best steps.

Comprehensive Assessment

Elements of the BHN assessment may include the following:

• Cognitive screening using validated paper or digital tools (eg, Montreal Cognitive Assessment, Mini-Mental State Examination, Saint Louis University Mental Status, Mini-Cog, commercially available digital cognitive assessments)
• Functional evaluation of daily activities (eg, managing finances, cooking, managing medications)
• Caregiver and safety assessment (eg, stress, burden, home safety risks)
• Neuropsychiatric and medical review (eg, depression screening, sleep quality evaluation, medication reconciliation)

Cutoffs for cognitive screening tools may vary and should be interpreted in conjunction with clinical judgment; for example, Dartmouth Health uses the Mini-Cog with a cutoff of ≤3 and the Montreal Cognitive Assessment with a cutoff of <26 for cognitive screening.

Care Coordination and Follow-Up

BHNs can triage and coordinate appropriate next steps on the basis of assessment findings and local clinical workflows, such as:

• Ordering blood tests or neuroimaging (according to their scope of practice and organizational protocols)
• Arranging specialist consultations or referrals (eg, neurology, neuropsychology, geriatrics)
• Connecting families to community resources or caregiver support groups
• Recommending interventions for addressable factors (eg, sleep disorders, hearing loss)
• Providing education about brain-healthy lifestyle choices

Ongoing Navigation and Communication

BHN involvement continues throughout the diagnostic journey. Navigators maintain regular contact with patients and their care partners, follow-up on appointments, facilitate communication among providers, coordinate medical record sharing, and ensure continuity of care. The duration and level of support vary on the basis of individual needs and local implementation models. Some sites provide navigation through the diagnostic phase; others maintain a more long-term relationship with patients and their families, continuing support throughout the disease course.

The BHN Model in Practice

The components of the BHN model provide a standardized yet flexible framework that facilitates early detection, improves the patient experience, and reduces care fragmentation across diverse health care settings. The BHN model accommodates various implementation strategies depending on local structures, and the BHN role can provide clinical as well as nonclinical support. Some sites position the BHN within primary care clinics to strengthen frontline assessment capabilities; others embed navigators within specialty memory clinics to facilitate appropriate referrals. General neurology clinics represent another valuable setting for BHN implementation, as neurologists often receive high volumes of memory-related referrals and can have long wait times. In these settings, navigators can help triage individuals to appropriate levels of care or available resources. Hybrid models with navigators supporting both primary and specialty care are also used. This flexibility allows health care systems to adapt the model to existing workflows while maintaining core coordination functions.

“The greatest impact of my role as a brain health navigator is helping patients and families feel supported and empowered during a confusing and emotional time. I guide them through diagnosis, treatment, and care planning—making sure they never feel alone in the process.”

—Catrina Archambault, MA, BHN (Memorial Healthcare)

Case Example: BHN Intervention Prompting Urgent Cardiac Treatment in a Patient With AD

An individual with AD, age early 70s, had previously sought care at 2 dementia specialty centers before self-referring to the Norton Neuroscience Institute Memory Center (Louisville, KY), where BHN services were requested by their spouse. The couple resides in a rural area ~50 miles from Louisville, with no local hospital access, presenting considerable care coordination challenges.

During a routine follow-up call, the BHN spoke with the patient’s spouse, who reported concerning episodes of syncope. Recognizing the clinical urgency beyond the dementia diagnosis, the BHN conducted a comprehensive assessment by telephone to gather detailed information about the frequency, duration, and circumstances of these episodes.

The BHN arranged for urgent cardiology follow-up and coordinated the logistics for specialty care access. The cardiologist ordered cardiac monitoring; the BHN actively tracked the cardiac monitoring results, and identified critical findings consistent with episodes of potentially fatal cardiac arrhythmias.

The BHN facilitated an emergent referral for pacemaker placement, which successfully treated the arrythmias. Since the intervention, no further syncopal episodes have occurred.

Implementation Insights and Challenges

All participating health care systems successfully established and hired BHN positions within 6 months of the program launch, demonstrating real-world feasibility. Navigators effectively coordinated patient–provider interactions, delivered brain health education, and streamlined diagnostic pathways. Initial anecdotal feedback from patients and their families has been overwhelmingly positive.

However, implementation revealed important challenges. Early administrative work proved more demanding than expected. Sites needed time to build scheduling systems, develop billing processes, clarify navigators’ responsibilities within existing staffing, and integrate referral pathways into electronic health records.

Achieving institutional support for sustainability requires demonstrating value to health care executives, who prioritize measurable operational benefits, such as patient retention, efficient resource use, and revenue generation. Building business cases with clear financial projections proved essential yet challenging, necessitating collaboration with business analysts and billing specialists who could translate clinical processes into financial terms.

Despite these challenges, sites reported steady increases in referrals, improved communication among departments, more efficient pathways from primary care to specialty evaluation, and elevated care quality. The program developed processes for selecting appropriate billing codes, creating templates and workflows that support revenue generation. More than 250 participants were enrolled across sites throughout 2025, with positive claims payment demonstrating financial viability.

“The brain health navigator role has proven to be both clinically impactful and financially sustainable at Norton Healthcare. By coordinating care across our system, we’re ensuring patients receive the right care at the right time while creating measurable value for our organization. This model isn’t just the future of dementia care—it’s becoming the standard of care.”

—Gregory Cooper, MD, PhD (Neurologist, Norton Healthcare)

Training and Education Requirements

Successful BHN implementation requires investment in training at multiple levels (Table). As part of the BHN program, sites created electronic health record–integrated tools, including customized history-taking templates, patient tracking systems, ongoing education and training resources, and standardized care pathways for detecting and managing individuals with cognitive impairment. Ongoing education and clear communication about the BHN role increased both the number and appropriateness of referrals. Securing executive support beyond the initial clinical referral proved imperative for system-wide scaling and long-term sustainability at several sites.

Billing and Financial Sustainability

Revenue generation emerged as a central concern for long-term viability. Sites identified several billing opportunities, including Principal Care Management codes for individuals with single high-risk chronic conditions, Principal Illness Navigation services for prediagnosis care coordination, and the Cognitive Assessment and Care Plan Service code for comprehensive cognitive assessment.

Successful billing requires careful documentation of time spent on billable activities (eg, assessing individual needs, creating care plans, coordinating with providers, communicating with patients and families). Sites developed standardized templates to meet billing requirements while supporting efficient workflows and worked closely with billing specialists familiar with Medicare requirements.

The economic benefits of the BHN model extend beyond care reimbursement to include improved patient retention, more appropriate utilization of specialty care resources, reduced emergency department visits through better care coordination, enhanced institutional reputation, and positioning for value-based payment models. Several sites demonstrated value by showing how the increased patient volume offsets the navigator’s salary.

The Path Forward

The BHN model represents a promising approach for addressing fragmented AD care pathways. By establishing boundary-spanning coordination roles, BHN programs enable health systems to bridge care gaps and create sustainable infrastructure for current interventions and emerging treatments. The model has potential for broad adoption across US health care systems, adaptable to diverse settings, from rural community hospitals to large academic medical centers.

The results and resources from the 6 pilot sites were developed into a prototype BHN Model Toolkit providing downloadable resources on clinical workflows, billing and business case guidance, and training materials, freely available at www.dacblueprint.org/dac-brain-health-navigator.

Key success factors include a tenacious local champion, early buy-in from primary care leadership and frontline staff, workflow integration and electronic health record tools, clear billing processes with appropriate documentation, quantifiable business cases, comprehensive training for navigators and referring providers, and flexibility for local adaptation while maintaining core program elements.

There is no universal method for implementing a BHN program. The intersection of well-designed care pathways and billing models creates a viable substrate for a sustainable BHN program, but each health care system will need to adapt the model to its unique circumstances. Pilot sites have demonstrated that various health care providers, including social workers, registered nurses, and medical assistants, can effectively step into the BHN role, provided they receive appropriate training and support.

As health care systems worldwide prepare for the growing impact of AD, the BHN model offers a feasible and sustainable approach to transforming fragmented care into coordinated, patient-centered pathways. BHN program sites demonstrate that success is achievable when clinicians, administrators, and navigators work together, with families at the center of care.