How Jefferson Health and Independence Blue Cross are working to catch dementia early and support patients in primary care

Early detection of dementia remains a critical challenge in the U.S., with many cases of mild cognitive impairment going unnoticed until later stages of the disease. In a new initiative led by Jefferson Health and supported by Independence Blue Cross (IBX), the “Improving Dementia Care” program seeks to change that by embedding dementia screening and care coordination into primary care practices.

Jefferson Health, along with Penn Medicine and Temple Health, were named recipients of IBX’s 2026 Clinical Care Innovation Grants in January 2026, which fund programs aimed at improving outcomes and making healthcare more affordable. Jefferson’s project, led by professor of the department of psychiatry, neurology and ophthalmology, Barry Rovner, M.D., focuses mainly on enhancing dementia care in older adults through earlier identification and improved patient support.

“(Primary care) is the only place where a problem can be recognized and addressed and referred on to appropriate specialists if that is needed,” said James Ellison, M.D., M.P.H., a geriatric psychiatrist at Jefferson Health. “Primary care often recognizes cognitive disorders late, and when we recognize it later, there's less time to intervene in a helpful way.”

The program targets early cognitive impairment, which is frequently underdiagnosed. Subtle signs, such as missed medications, changes in self-care, difficulty managing finances or caregiver concerns about memory and daily function, tend to come before formal dementia diagnoses by years. Ellison noted that recent research has found roughly 90% of those with mild cognitive impairment go undetected in primary care settings, highlighting a significant gap in care.

Jefferson’s dementia care program integrates primary care providers, community health workers and patient caregivers in a structured model, as explained by Ellison and Rodrigo Cerdá, M.D., M.P.H., senior vice president and chief medical officer at IBX. Patients identified as high risk through electronic health records are contacted and invited to participate in the program, pending ethics committee approval and primary care physician consent. Once enrolled, they receive a comprehensive assessment and support, including guidance on next steps, testing and care planning.

In addition, community health workers play a pivotal role in this initiative. For example, unlike nurses or social workers, they focus on shared decision-making, helping patients and families clarify care priorities and understand the disease. These conversations are then shared with the primary care clinician, allowing physicians to make informed recommendations without overburdening already limited appointment times.

Cerdá said the grants are intended to catalyze change within the health system and encourage innovative care models.

“The Clinical Care Innovation program is a way to invest in our network in a way,” adding that the program can assess new approaches to care that improve quality, patient experience and the total cost of care.

The program is designed to compare outcomes between “enhanced usual care,” which includes standard screening and test ordering, and the intervention arm, where patients receive additional education and decision support from community health workers. This structure allows researchers to look at which methods most effectively improve early detection, diagnosis and care coordination.

Meaningful diagnosis extends beyond a positive screening result.

Ellison expressed that it requires differentiating among various forms of dementia — Alzheimer’s, vascular, Parkinson’s, Lewy body or frontotemporal — while considering lifestyle factors, medication interactions and comorbid conditions. Spotting dementia early also gives doctors the opportunity to use new therapies that can slow down Alzheimer’s, helping patients improve when treatment starts sooner.

Additionally, non-pharmacological care is equally as important. Behavioral symptoms, such as apathy or agitation, can complicate dementia care and can precipitate crises or hospitalizations.

By intervening early, primary care providers can help families manage these behaviors at home, reducing the need for institutional care and supporting patient safety and quality of life. Pleasant event scheduling, engagement in meaningful activities and attention to medical contributors such as pain or sleep issues are examples of strategies applied in this model.

Ellison shared that the long-term goals of Jefferson’s program include extending the duration patients can safely remain at home, improving caregiver support and ultimately creating a scalable model that can be adopted across other health systems. Data analytics and artificial intelligence can assist in identifying at-risk individuals and tailoring interventions to their needs, with the potential to improve both outcomes and efficiency.

“If a positive screen for cognitive impairment is a smoke alarm, then the correct diagnosis is finding the fire, and providing appropriate care is salvaging the building with as little damage as possible,” Ellison said, highlighting the importance of early, precise intervention.