Provider,Interdisciplinary Staff,and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care

Abstract

Introduction:

In 2017, Medicare introduced the cognitive assessment and care plan (CACP) billing code to incentivize comprehensive care for people living with dementia (PLWD). CACP requires addressing 8 care domains. Adoption of CACP has been limited, particularly in primary care. We identified barriers and facilitators of implementing CACP in primary care.

Methods:

Primary care providers (PCP), interdisciplinary staff, and PLWD and/or caregivers from primary care practices participated in semi-structured interviews about dementia care. We applied content analysis methods to analyze qualitative data mapped to 3 CACP implementation outcomes: acceptability, appropriateness, and feasibility.

Result:

Most participants found CACP acceptable due to its comprehensive nature and addressing unmet needs. PCPs and staff felt CACP was appropriate for primary care because they were already addressing many of the required care domains during Medicare Annual Wellness Visits (AWV). Concerns about the time, resources, and coordination needed made feasibility unclear. Potential strategies for implementation included using interdisciplinary team members, data and workflows from AWV implementation, and health information technology.

Conclusions:

CACP is acceptable and appropriate for primary care though comprehensiveness and requirements limit feasibility. Implementation strategies must address time, resource, coordination, and awareness/education needs to successfully deliver this Medicare benefit at a large scale.

Keywords

dementia care planning primary care implementation medicare

Introduction

Nearly 7 million Americans are living with dementia, but many are undiagnosed and those diagnosed often receive suboptimal dementia care within the healthcare system.^1-6 Detecting dementia and subsequent care planning can help improve outcomes and address information needs for people living with dementia (PLWD) and their caregivers.^7,8 Primary care providers (PCPs) are often expected to recognize, diagnose, and manage dementia, but numerous barriers exist to proactive detection and care.⁹ In addition to patient- and family-level challenges such as stigma, PCPs have reported discomfort discussing dementia, limited dementia-specific training, low reimbursement, time constraints, and limited health system support as barriers to dementia care.^9-15

In 2017, The Centers for Medicare and Medicaid Services (CMS) introduced a billing code for cognitive assessment and care plan (CACP) services to incentivize clinicians to provide comprehensive dementia care.¹⁶ CACP services require assessing 8 dementia-related care domains (Figure 1) and developing a written care plan. Any provider eligible to bill for evaluation and management services can deliver CACP including primary care, where most dementia diagnosis and care occurs.^16,17 CACP has had very low uptake and adoption. Less than 1% of Medicare beneficiaries with an Alzheimer’s diagnosis received CACP 2 years after it was introduced.^18-20 There has been little research into barriers limiting CACP implementation. This qualitative study takes a multi-stakeholder approach to identify barriers and facilitators to providing/utilizing CACP services in primary care, focusing on CACP acceptability, appropriateness, and feasibility from PCP, interdisciplinary staff, and PLWD/caregiver perspectives. Interdisciplinary staff with potential involvement in coordinating and conducting CACP or addressing the resulting care plan were included in the study: registered nurses, medical assistants, care managers, pharmacists, practice administrators, and social workers.

Figure 1.

Implementation outcomes for cognitive assessment and care plan services.

Methods

Our study methods, previously described in detail,²¹ are also outlined per the consolidated criteria for reporting qualitative studies in Supplementary Table 1.²² We drew from 23 community-based primary care practices within a single academic-affiliated health system participating in a state-level primary care program focused on prevention and chronic disease management. Practices had access to interdisciplinary teams, health information technology, and care management services.²³ We used maximum variation sampling to recruit PCPs and interdisciplinary primary care staff (registered nurses, medical assistants, care managers, pharmacists, practice administrators, social workers) via e-mail from practices with differing locations/access to specialty care and patient population demographics (age ≥ 65, dementia diagnoses, Black race, and Hispanic ethnicity). There were no rural practices in the health system, but several were located more than 30 miles from tertiary care centers. PLWD and/or their caregivers were identified through medical record screening of 500 randomly selected patients diagnosed with dementia in the past 10 years and seen within the past 2 years. Eligible PLWD or caregivers were recruited via mailed letters followed by phone calls if there were no objections to recruitment by their PCP. Participants provided oral consent. Supplemental Figure 1 shows a flowchart of recruitment for PLWD. The protocol was approved by our institution’s Institutional Review Board.

From July 2021 to January 2023, two investigators (HA and/or MDB, researchers with clinical geriatrics and social work backgrounds, respectively) conducted semi-structured interviews via Zoom or telephone using role-specific interview guides. Interviews were approximately 1 h long and were recorded and then later transcribed by a transcription service. Interviews focused on dementia care with specific questions about CACP (Supplemental Text 1). Participants were provided a 1-page CACP overview (Supplemental Text 2) and/or a verbal description of CACP. Topics included familiarity with and reactions to CACP, barriers/facilitators to delivering CACP, and fit with their role.

Transcripts were analyzed using content analysis.²⁴ Three investigators (HA, MDB, and EA, an undergraduate neuroscience student trained by HA and MDB) coded transcripts using a codebook based on literature, research objectives, and emerging data, including 4 CACP-specific codes: “general reaction,” “implementation potential,” “already doing,” and “not doing.” Each transcript was coded by 2 investigators and then reconciled using NVivo qualitative analysis software (version 12, QSR International; Burlington, MA). Coding was discussed during weekly team meetings to optimize consistency. To reconcile each double coded transcript, the third investigator reviewed all codes within the transcript that had less than 95% agreement based on inter-rater reliability. Most disagreements were reconciled by the third investigator while some were brought to the team for discussion and reconciliation.

Two additional investigators (OO and JFM, an undergraduate biology student and a health services researcher, respectively) analyzed relevant coded data to identify themes that were discussed and refined during weekly team meetings. Themes were grouped around outcomes relevant to CACP implementation: acceptability, appropriateness, and feasibility of CACP in primary care (Figure 1).²⁵ Acceptability was defined as the degree to which CACP is agreeable or satisfactory to participants. Appropriateness was the perceived fit, relevance, or compatibility in primary care. Feasibility was the degree to which CACP can be realistically delivered in primary care. Representative quotes are presented for each theme and include participants’ unique study identifiers.

Results

The study sample (Table 1) included 5 PCPs, 23 interdisciplinary staff, and 15 PLWD and/or their caregivers affiliated with over 13 unique practices. Two PLWDs participated alone, 5 interviews were caregiver only, and 8 were PLWD/caregiver dyads. Of note, only 1 PCP and 3 interdisciplinary staff were familiar with CACP prior to the study; all other participants did not know of this Medicare benefit.

Table 1.

Study Participant Characteristics.

Characteristic	N (%) or Mean (SD)
Primary care physicians and staff (n = 28)
Staff category, n (%)
Primary care physician or provider	5 (17.9)
Registered nurse	5 (17.9)
Medical assistant	4 (14.3)
Practice administrator	3 (10.7)
Care manager	5 (17.9)
Social worker	3 (10.7)
Pharmacist	3 (10.7)
Female sex, n (%)	27 (96.4)
Race, n (%)
White/Caucasian	16 (57.1)
Black or African American	5 (17.9)
Asian	4 (14.3)
Not specified or mixed race	2 (7.1)
Hispanic/Latino ethnicity, n (%)	4 (14.3)
Years since graduation, mean (SD)	34.6 (9.8)
Years with current practice(s), mean (SD)	4.8 (2.9)
Person living with dementia (n = 15)
Age, mean (SD)	84 (7.7)
Female sex, n (%)	11 (73.3)
Race, n (%)
White/Caucasian	8 (53.3)
Black or African American	5 (33.3)
Asian	1 (6.7)
Not specified or mixed race	1 (6.7)
Hispanic/Latino ethnicity, n (%)	1 (6.7)
Education, n (%)
High school	6 (40)
Some college or college degree	3 (20)
Graduate or professional degree	4 (26.7)
Not specified	2 (13.3)
Years since documented dementia diagnosis, mean (SD)	3.3 (1.5)
Caregiver (n = 13)
Age, mean (SD)	75.4 (12.1)
Female sex, n (%)	8 (61.5)
Race, n (%)
White/Caucasian	8 (61.5)
Black or African American	3 (23.1)
Asian	2 (15.4)
Hispanic/Latino ethnicity, n (%)	0 (0%)
Education, n (%)
High school	1 (7.7)
Some college or college degree	5 (38.5)
Graduate or professional degree	7 (53.8)
Relationship to PLWD, n (%)
Spouse	10 (76.9)
Child	2 (15.4)
Sibling	1 (7.7)

Abbreviation: PLWD, person living with dementia.

Table 2 summarizes themes related to acceptability, appropriateness, and feasibility of CACP in primary care with representative quotes. CACP was felt to be acceptable and appropriate for primary care but feasibility was unclear.

Table 2.

Themes and Representative Quotes Related to Potential Implementation of Cognitive Assessment and Care Planning in Primary Care.

Outcome	Theme	Quote
Acceptability	Generally acceptable	“For the time involved and the commitment. . . I would follow through with that [the written care plan].” – Participant 107, CG
		“I would look at it [the written care plan] because that would give me some kind of idea what to do, where to start or something like that.” – Participant 122, CG
		“I think, is really important, and I mean even the fact that this Medicare visit thing that would pull everything together so it would be summarized and concise . . . I think that's huge.” – Participant 91, PCP
	Vague requirements	“So, it just seems like you could do a lot of things and . . . it's not clear to me anyway what Medicare would say, 'Oh, that's good enough and that's not.'” - Participant 91, PCP
Appropriateness	Already doing many CACP elements	“. . . I do the PHQ-2 or 9 . . . I always review medications. Certainly, you’re always discussing caregiver identification, who’s at home, who helps, and the advanced care planning is also part of the health risk assessment. So, I feel like we address a lot of these issues already when we do their Medicare Wellness.” - Participant 42, PCP
		“. . . I think I would have done all of this stuff, but I'm not sure I would have done it all at once. I think that they're all individually easy to address. ” – Participant 91, PCP on CACP domains
		“. . . we're doing a PHQ-2, for example. Obviously, we're doing medication reviews and like during Medicare Wellness exam we're doing such things as asking about safety issues.” – Participant 94, RN
	Dementia staging not currently done in primary care	“. . . I don't usually necessarily stage dementia, so that would just be something new to–you know, to incorporate.” – Participant 10, PCP
	Dementia staging not currently done in primary care	“I’ve done dementia staging with people who are kind of getting pretty severe in their dementia stages . . . But I don’t use this on a regular basis at all.” – Participant 40, PCP
	Primary care vs specialist completion	“Well, I think that definitely, we’re the front line to recognize people who might have these issues and then to assist to diagnose and get the proper treatment to the patient. So, we’re kind of key.” – Participant 42, PCP
		“Well, someone who specially knows about these issues, I mean, this is no knock on [PCP], but he's not a specialist in this. He knows a lot about it but not a specialist . . . better if the person doing it were a specialist in it. ” – Participant 107, CG
		“. . . that would be more of the memory clinic thing–I don’t know how PCPs feel about staging the severity or level.” – Participant 52, SW
Feasibility	Time challenges	“What is this written care plan, and who has the time for this?. . . Testing memory also takes a while, right? Especially if I'm doing it myself. That takes a long time.” – Participant 40, PCP
		“I think it's a large asking. . . I also just think about doctor's appointments and how pressured they are . . . The course of evaluations are going to take a significant amount of time.” – Participant 23, Care manager
		“. . . I think that the problem can be the time.” – Participant 41, MA
	Staff and coordination challenges	“I think that that's the main concern here. . . the lack of communication and the lack of knowledge of what our social workers are supposed to do, and can do for us and our patients . . .” – Participant 11, Practice administrator
		“. . . it would be complicated coordinating between when they [interdisciplinary staff] can come in and seeing the patient that we have currently versus like are they going to different sites? I think that would be a time coordination issue there.” – Participant 94, RN
		“ I worry that. . . without somebody or somehow some additional support to look at some of these things, it’s just not possible for them. . . figuring out how is it even possible if you don’t have the support services to surround it.” – Participant 51, Practice administrator
	Implementation solutions	“. . . if there was built in into the computer a way to pull it all together or a form that pulled it all together, then I could do it. Yeah, I could do it in a dedicated visit.” – Participant 91, PCP
		“. . . if they're active on MyChart, we try to send everything that they need prior to the appointment, to get done beforehand.” – Participant 11, Practice Administrator
		“I think the quality metric is definitely a huge push for them to get [Annual Wellness Visits] scheduled and get them completed. . . we're trying to stay on top of those quality metrics and get them done as soon as the patients come in. . .” –Participant 11, Practice administrator

Abbreviations: CACP, cognitive assessment and care plan; CG, caregiver; SW, social worker; PCP, primary care provider; RN, registered nurse.

Acceptability

All participant types felt CACP was acceptable. PLWD and caregivers reacted favorably to CACP in general and the care domains covered. One caregiver (participant 161) commented, “Very good. I think that anything that's preemptive and a possibility to get people prepared is the best thing you could possibly ask for.” Caregivers also commented on how the written care plan would be useful for navigating caregiving responsibilities. PCPs and staff acknowledged the value added by the comprehensive nature of CACP. A social worker (participant 54) reflected, “All these different pieces are kind of consolidated into the same assessment. So I would think that it would be pretty helpful for the patient and their family.” Interdisciplinary staff expressed willingness to help address care domains that aligned with their role or scope of practice.

Though participants responded positively to CACP, a few raised concerns that CMS requirements were vague and could result in superficially addressing care domains. A social worker (participant 90) remarked, “The doctor may do a checkbox to do the assessment, but may not always get an opportunity to talk with the caregiver about it.”

Appropriateness

Participants generally felt CACP was appropriate for primary care, with some reservations. Multiple PCPs and staff shared that many of the required care domains are already being addressed during the Medicare Annual Wellness Visit (AWV) or routine care. A PCP (Participant 20) responded to what they were already doing from the required care domains: “I think basically you're addressing all of them. It is just basically putting it into the. . .protocols.” PCPs and staff were using specific instruments recommended for certain domains, such as the Patient Health Questionnaire for depression screening. PCP participant 20 described existing efforts to incorporate caregivers into visits in the context of CACP requirements for caregiver identification and assessment, “. . .we have always encouraged it . . . as a . . . practice to always bring the other person in, because often they are the bridge for a lot of other stuff . . . Otherwise it's kind of going to be a wasted visit.” PCPs, staff, and PLWD/caregivers who viewed CACP as particularly appropriate for primary care felt a PCP would be well-positioned to identify and address dementia care needs due to having an established relationship with the patient. A caregiver (participant 188) commented, “everything has to be addressed pretty much as soon as you notice it. . . primary care, especially if they've been seeing the patient for a while would notice, and then would be able to make things a little bit easier going forward.”

Though many CACP elements were already being delivered in primary care, some PCPs and staff noted dementia staging was not consistently being done in primary care. Some participants felt CACP may be more appropriate for specialty care. A registered nurse (participant 94) reacted to the staging requirement saying, “Dementia staging and all, I don't know necessarily that that's something PCP should do. I think more neuro. . .”

Feasibility

Participants were unsure whether CACP was feasible in primary care. Time constraints, recognized even by PLWD and caregivers, posed the most significant challenge. PCPs and administrators expressed concerns about having enough time to complete all CACP elements, particularly creating the written care plan. A PCP (participant 10) commented, “If we're going to run through, . . . all of these categories, it could. . .take a lot of time.”

PCPs and administrators thought it could be challenging to coordinate the roles of different team members and track which individual elements had been previously completed if bringing together a CACP visit using prior assessments. A PCP (participant 91) described their concerns about tracking assessments, “. . . how to bring it in in an organized way so that the provider knows that it's been done, especially if it's been over time by different people . . ..” One PCP (participant 20) had attempted CACP visits via telehealth and experienced challenges delivering some of the assessments to patients over video.

Participants proposed several ways to address time and coordination challenges. The ability and allowance to complete CACP elements over multiple visits was a way to fit CACP into existing scheduling blocks, which allotted more time for older patients. PLWD and caregivers could also complete assessments beforehand, such as through the patient portal. A PCP (participant 10) described, “I mean, as long as we have all the resources we need to schedule it. . . maybe we could give patients the paperwork ahead of time. . .” A caregiver (participant 123) also expressed their familiarity with completing assessments via a patient portal and their willingness to do so for CACP: “I don't have any problem with that. I have to do that anyway for most of my specialists.” PCPs and staff felt interdisciplinary staff completing some aspects of CACP in a team-based approach would make it more feasible, including consideration of having a nurse-led visit. One nurse (participant 92) described their willingness to assist, “. . . the first thing that came to my mind is whether providers would be willing to allow the RNs to do this. . . But certainly, with the proper training . . . I think it would work.” PCPs and staff also acknowledged the experience and success of implementing the AWV within their practices could be used for CACP, using a team-based approach and leveraging electronic medical record capabilities (patient portal, visit templates, tracking). Administrators noted that using AWVs as a quality metric motivated their implementation at the system-level, providing a model for other initiatives.

Relevant to feasibility, almost all participants, including PLWD and caregivers, were not aware of CACP as a service or its specific requirements prior to the interview. PCPs and staff felt education and training would be needed to implement CACP.

Discussion

As initiatives to improve dementia diagnosis and care expand, this study is the first to qualitatively explore the underused CACP benefit in primary care. Forty-three participants with diverse roles shared their perspectives. A key finding was that most participants, including providers, were unaware of CACP or its components. However, they found it acceptable and believed its domains and care plan would benefit PLWD and their families. CACP was seen as suitable for primary care, as many required elements are already being addressed in primary care. Many reported that established provider/patient relationships support primary care implementation, though some preferred specialist involvement.

CACP feasibility in primary care is limited by systemic barriers, especially lack of awareness and time constraints – issues echoed in broader research on dementia care and other Medicare benefits.^{9-11,13-15,21} Addressing these through staffing, coordination, and education is essential. CMS, other organizations, and health systems could help by promoting resources and training such as the Alzheimer’s Association toolkit, especially for CACP elements for which PCPs and staff are less comfortable.²⁶ PCPs could benefit from training in dementia staging and tools like the Quick Dementia Rating System.²⁷ CMS might also revise complex elements such as staging if they remain a barrier. Time constraints could be reduced by spreading CACP across visits, team-based care, and using patient portals – though this requires coordination and tracking. Integrating data from previous visits, including AWVs, into CACP templates could improve efficiency.

Future research should explore how to embed CACP into primary care workflows, and how it can complement new care interventions and treatments.^27-29 For example, CMS introduced the Guiding an Improved Dementia Experience (GUIDE) Model in 2024, facilitating comprehensive dementia care navigation and support.³⁰ CACP remains relevant as GUIDE will only support a small fraction of PLWD nationally and excludes Medicare Advantage. Moreover, GUIDE program workflows suggest billing for CACP services for PLWD ineligible for GUIDE and could help identify PLWD who would most benefit from GUIDE services. As early diagnosis of dementia increases with the use of blood biomarkers and new treatments, CACP can also facilitate proactive care planning, education, and support.

Study limitations include generalizability as participants are drawn from different community-based practices but within a single health system with access to interdisciplinary teams and high rates of AWV completion. Other primary care settings may not address as many CACP elements during routine care or have the same resources, particularly in terms of training, support staff, and electronic health record infrastructure. Acceptability, appropriateness, and feasibility may differ in other systems or practices, and CACP implementation should be considered in the local context. Recruited participants may also have been more enthusiastic about dementia care than the general patient/provider population.

This study suggests that CACP, an existing Medicare benefit for comprehensive dementia care, could be more widely adopted in primary care. Successful and sustained implementation requires addressing feasibility challenges at national and local levels. Health systems and CMS should help support strategies that address time, staffing, coordination, and education needs, and CMS might consider changes to reimbursement or requirements. Local strategies may include building upon AWV workflows, using interdisciplinary teams including nurses, and optimizing health information technology. Implementation should build on PCP, staff, PLWD, and caregiver attitudes which find CACP to be acceptable and appropriate, adding value and quality to primary care.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251393871 – Supplemental material for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care

Supplemental material, sj-docx-1-jpc-10.1177_21501319251393871 for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care by John F. Mulcahy, Obehiaghe Oniha, Emmanuel Angomas, Elizabeth Kelly, Maura McGuire, Jessica L. Colburn, Jennifer L. Wolff, Cynthia M. Boyd, Quincy M. Samus, Marcela D. Blinka and Halima Amjad in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-2-jpc-10.1177_21501319251393871 – Supplemental material for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care

Supplemental material, sj-docx-2-jpc-10.1177_21501319251393871 for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care by John F. Mulcahy, Obehiaghe Oniha, Emmanuel Angomas, Elizabeth Kelly, Maura McGuire, Jessica L. Colburn, Jennifer L. Wolff, Cynthia M. Boyd, Quincy M. Samus, Marcela D. Blinka and Halima Amjad in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-3-jpc-10.1177_21501319251393871 – Supplemental material for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care

Supplemental material, sj-docx-3-jpc-10.1177_21501319251393871 for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care by John F. Mulcahy, Obehiaghe Oniha, Emmanuel Angomas, Elizabeth Kelly, Maura McGuire, Jessica L. Colburn, Jennifer L. Wolff, Cynthia M. Boyd, Quincy M. Samus, Marcela D. Blinka and Halima Amjad in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-4-jpc-10.1177_21501319251393871 – Supplemental material for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care

Supplemental material, sj-docx-4-jpc-10.1177_21501319251393871 for Provider, Interdisciplinary Staff, and Patient Perspectives on the Potential for Cognitive Assessment and Care Plan Services in Primary Care by John F. Mulcahy, Obehiaghe Oniha, Emmanuel Angomas, Elizabeth Kelly, Maura McGuire, Jessica L. Colburn, Jennifer L. Wolff, Cynthia M. Boyd, Quincy M. Samus, Marcela D. Blinka and Halima Amjad in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We thank the members of the Primary Care Memory Support Study Advisory Board for providing guidance on interview questions and topics.

ORCID iD

John F. Mulcahy

Ethical Considerations

The protocol was approved by the Johns Hopkins Medicine Institutional Review Board.

Consent to Participate

Participants provided oral consent to be interviewed for this study.

Consent for Publication

Not applicable.

Author Contributions

All listed authors have:

– Made a significant contribution to the concept, design, acquisition, analysis or interpretation of the data in this manuscript.

– Drafted the article or revised it critically for important intellectual content and/ or approved the final version of the article for publication.

– Agreed to be accountable for all aspects of the work and resolve any issues related to its accuracy or integrity.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Institute on Aging K23 AG064036, the National Institute of Aging K24 AG056578, and the National Institute of Aging T32AG066576-01.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The dataset generated and analyzed is not publicly available to protect participant confidentiality but may be made available from the corresponding author on reasonable request and Institutional Review Board permission.

Supplemental Material

Supplemental material for this article is available online.

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