Integrating A Population Health-based System And Academic Memory Assessment Program To Support The DAC-SP Early Detection Blueprint

History: To support the growing aging population and address the needs of persons living with Alzheimer’s Disease and related dementias (ADRD), Virtua Health and Rowan-Virtua School of Osteopathic Medicine, partners on a DHHS-HRSA Geriatrics Workforce Enhancement Program (GWEP) and CMS GUIDE Model, collaborated on the Davos Alzheimer’s Collaborative U.S. Early Detection Program using the DAC-SP Blueprint.  The goal was to create structures and processes to support early detection in a 5-hospital regional health system with 37 primary care practices linked with an academic Memory Assessment Program (MAP). This update of the AAIC 2025 poster presents data collected from initial DAC-SP planning and activation in January-September 2025 in 5 primary care pilot sites, reporting results at 4 months and 9 months (December 2025, May 2026), with preliminary data for systemwide integration and implementation (February-March 2026) across all 37 practices.  Preliminary data demonstrate scalability and support sustainability in a population health-based system committed to developing a geriatric service line to better serve older individuals, persons living with dementia, families, and caregivers.

Results: *Baseline: Prior to implementation of the DAC-SP Early Detection program <25% of primary care patients were screened annually for cognitive impairment during the Medicare Annual Wellness Visit (AWV) and 2.5% had a confirmed diagnosis of dementia (national average 10.9%)

5 Pilot Practies (December 2025 & may 2026): Growth in cognitive screening and downstream clinical interventions occurred across five pilot primary care practices from December 2025 to May 2026. Increased screening volume was associated with higher rates of diagnostic evaluation, specialty referral, and cognitive impairment diagnosis, supporting the effectiveness of a primary care-based early detection model.

Preliminary Data on Systemwide Rollout - 37 Practices (May 2026): Within three months of systemwide implementation, 4,946 patients were screened for cognitive impairment, resulting in over 2,400 patients identified as at risk, 130 new diagnoses, 70 neurology referrals, and initiation of advanced treatment and support services, demonstrating the scalability and clinical impact of a primary care-based cognitive care model.

Conclusion: A year after launch of the DAC-SP Early Detection U.S. Fellowship Program, 37 Virtua Medical Group primary care practices are engaged in early detection of cognitive impairment. Population Health Nurses (PHRNs) support  clinicians in conducting Medicare AWVs [based on the 4Ms framework] and Linus Core Cognitive Evaluation (Linus DCR/LHQ). A follow-up Cognitive Assessment Visit in primary care for patients with cognitive problems includes a customized Dementia Standing Order Set in Epic (labs, medication review, assessment of contributing factors, ADLs/IADLs, MoCA, PHQ-2, Linus Digital Assessment of Cognition test battery); e-Consults, advanced cognitive workup [ATN Profile, Aβeta 42/40, p-Tau 181, p-Tau 217; APOE Genotyping; amyloid PET CT] and streamlined referral pathways to neurology, neuropsychology, Memory Assessment Program (MAP), GUIDE, anti-amyloid therapy. Increases in AWVs,  early identification of cognitive impairment, dementia diagnoses are reflected in increased in-system referrals. Preliminary results demonstrate scalability and systemwide integration. Continued provider/staff dementia education and support are critical to maintaining a sustainable model for early detection of cognitive impairment and quality dementia care.