ToolBox Detect: Low Cost Detection of Cognitive Decline in Primary Care Settings

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PROJECT SUMMARY Our objective is to widely implement and evaluate a user-centered, scalable, electronic health record (EHR) - linked strategy for the routine detection of cognitive decline among diverse primary care settings. Cognitive impairment is most prevalent among adults 65 and older, yet less than half of cases are detected and/or diagnosed in primary care settings. It is now increasingly accepted that early detection is critically important to optimize care planning, sustained independence, management of chronic conditions and appropriate caregiver involvement. In 2011, Medicare initiated a covered, Annual Wellness Visit (AWV) that includes a cognitive assessment to detect impairment, Alzheimer’s disease and related dementias (ADRD). While this has presented new opportunity for case finding, implementation of AWVs has been variable, including how cognitive function is assessed. Clinicians may rely on more basic, paper-based, interviewer-administered tests that may be less precise and more cumbersome to clinical workflow – affecting the fidelity of an early detection strategy. Further, many practices lack a clear protocol for referral when impairment is determined, and a process for family involvement and establishing care goals. Practical, sustainable, scalable strategies are urgently needed to help primary care providers who are on the frontlines of healthcare routinely assess cognitive function as part of AWVs (or whenever a cognitive impairment is suspected), identify concerns and have a protocol for referrals and care management. This is especially true for resource-constrained clinical settings, such as Federally Qualified Health Centers (FQHCs) caring for more vulnerable patient populations. Northwestern developed and continues to innovate the NIH Toolbox for the Assessment of Neurological and Behavioral Function®. Since 2017, our team has worked closely with primary care practices to develop a brief, technology-enabled, self-administered, EHR-linked cognitive assessment derived from the NIH Toolbox. We also devised a detailed protocol for its use and how results of our test, known as ToolboxDetect, can inform patient care. We propose a large-scale, primary care practice-randomized trial to implement and comprehensively evaluate ToolboxDetect as a standard of care with AWVs, linked to an EHR (Epic). Diverse, academic and community settings are included to optimize future dissemination efforts. Our primary aim is to evaluate the effectiveness of ToolboxDetect, compared to enhanced usual care, to promote timely detection of cognitive decline and its care management. Our secondary aims are to: 2) Disseminate and implement ToolboxDetect among a large Federally Qualified Health Center Network and assess its feasibility and acceptability for use; 3) Investigate the fidelity of ToolboxDetect, and identify any patient, caregiver, healthcare provider and/or system barriers to its optimal, sustained implementation; and 4) Determine costs associated with implementing ToolboxDetect from a primary care perspective.