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Brain Health Navigator: Jobs to Be Done Checklist

A systematic checklist of jobs to be done to support the creation of a job description for a boundary-spanning Brain Health Navigator role.

📋 Instructions

As you review the list, please select only the line items that are relevant to your Health System's needs. If you are aware of where a specific item will be carried out, indicate either Primary Care or Specialty to help determine where a boundary-spanning role may be most effectively positioned within your system. Additionally, if you know whether the task will be completed by clinical or non-clinical personnel, please check the appropriate column. Totals will be automatically calculated at the end. This summary can be used to help identify which Business Model Archetype may best represent your system.

Please note: This list is comprehensive by design and is not intended to have every row completed. This checklist is intended to be used in conjunction with the other Brain Health Navigator Model tools.

Initial Clinical Assessment Activities - Early Detection and Screening
Patient Identification and Clinical Preparation:
Primary Care Specialty Clinical Non-Clinical Task
Risk Factor Identification - Flag patients with cognitive decline through Electronic Medical Records case finding (Chronic Kidney Disease, Cardiovascular Disease, diabetes, smoking, frequent missed appointments, heavy Healthcare System resource use, frequent Emergency Department visits)
Brain Care Risk Score - Establish automated scoring and case finding algorithms
Community Outreach - Coordinate with senior centers, churches, and community organizations
Provider Education - Conduct outreach and education as necessary
Comprehensive Patient Assessment:
Primary Care Specialty Clinical Non-Clinical Task
Medication Review - Assess concomitant medications and health history
Cognitive Assessment Administration - Cognitive Assessment instruction, administration, and documentation
Social Determinants Assessment - Conduct Social Determinants Of Health (SDOH) assessment if applicable, refer to social worker per protocol
Substance Use Evaluation - Assess tobacco, alcohol, and recreational substance/illicit drug use, refer for treatment per protocol
Cardiovascular Risk Assessment - Perform Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment if applicable
Medication Audit - Review American Geriatrics Society (AGS) Beers Criteria®, Anticholinergic Burden (ACB), medications contraindicated in potential future treatment
Functional and Cognitive Evaluation:
Primary Care Specialty Clinical Non-Clinical Task
Dementia Risk Assessment - Evaluate family medical history, Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) function
Physical Function Assessment - Assess IADL, ADL, gait, and balance difficulties. Refer to Physical Therapy/Occupational Therapy, per protocol
Cognitive Screening - Perform comprehensive cognitive screening and assessment
Sleep Evaluation - Evaluate sleep difficulties (STOP Bang), order sleep medicine referral per protocol
Hearing Assessment - Perform hearing screening, refer to RN for external ear canal examination, refer to audiology per protocol
Family Interview - Interview family members who may have concerns
Care Coordination and Documentation:
Primary Care Specialty Clinical Non-Clinical Task
Consent Documentation - Obtain and document consent for navigation/care coordination services (required for Medicare billing)
Medical Records Management - Obtain and disseminate outside medical records or send system records to outside providers
Care Pathway Triage - Determine appropriate next level of care per protocol (specialty vs. primary care, per local workflow)
Appointment Coordination - Assist with scheduling all appointments, follow up on missed appointments
Referral Management - Ensure all referrals are completed and results are accessible for diagnostic visits
Clinical Documentation - Document all time spent and support provided in medical record
Patient Education - Provide relevant educational materials
Post-Assessment Workup Activities - Clinical Follow-up and Additional Testing
Laboratory and Research Coordination:
Primary Care Specialty Clinical Non-Clinical Task
Laboratory Testing - Order rule-out tests per clinical protocol
Research Opportunities - Identify patients for research/clinical trials per protocol, escalate to research coordinator (optional)
Additional Medication Review - Conduct per clinical protocol requirements
Psychological Screening - Perform additional rule-out tests (depression, anxiety screening) per clinical protocol
Advanced Hearing Testing - Coordinate if needed based on initial screening
Sleep Study Coordination - Arrange sleep study/assessment if needed
Cardiac Evaluation - Order ECG per protocol if patient is candidate for Aricept
Communication and Care Coordination:
Primary Care Specialty Clinical Non-Clinical Task
Provider Communication - Communicate results and clinical follow-up/next steps with patient
Program Support - Provide time and effort for answering questions, review, and follow-up with patient
Follow-up Scheduling - Assist with scheduling follow-up care from corresponding providers
Documentation - Document all time and support provided in medical record
Clinical Escalation - Escalate significant/abnormal findings or concerns to appropriate healthcare provider
Social Work Referral - Escalate complex social/emotional or economic issues to social worker
Patient and Family Education - Educate on path forward and provide relevant materials
Advanced Neuropsychological Testing - Comprehensive Cognitive Assessment
Test Administration and Management:
Primary Care Specialty Clinical Non-Clinical Task
Test Administration - Conduct Cognitive Assessment test administration
Result Communication - Communicate Cognitive Assessment test patient results
Provider Consultation - Facilitate provider communication of results and next steps
Program Support - Provide ongoing support for questions, review, and follow-up
Data Management - Handle clinical follow-up, electronic data capture, and chart review/verification
Care Transition - Schedule and refer patient to next phase based on test results
Educational Support - Provide relevant patient education materials
Pathology and Diagnostic Confirmation - Accurate Diagnosis and Biomarker Testing
Medical Assessment and Imaging:
Primary Care Specialty Clinical Non-Clinical Task
Comprehensive Medical Assessment - Complete medical evaluation
Medical History Documentation - Collect medical history and concomitant medications if not available
MRI Coordination - Arrange and manage brain imaging
Laboratory Management - Coordinate blood draw, sample preparation, and shipping
Sample Processing - Manage vials and processing of results from laboratory
Results Communication - Provider communication of results and next steps
Program Support (Biomarkers) - Provide specialized support for biomarker patients
Data Management - Clinical follow-up, electronic data capture, and chart review/verification
Advanced Diagnostic Testing:
Primary Care Specialty Clinical Non-Clinical Task
CSF Testing - Coordinate lumbar puncture, sample preparation, and shipping
PET Imaging - Arrange PET scan for amyloid detection
Specialized Support - Program support for CSF/PET patients
Advanced Data Management - Patient assessment, clinical follow-up, and data verification for CSF/PET
Diagnostic Referral - Refer based on confirmatory diagnosis
Treatment Planning - Develop and document clinical management plan
Provider Communication - Communicate with referring providers
Patient Education - Provide relevant educational materials
Lifestyle Resources - Connect to supportive resources (gym memberships, nutritional resources, etc.)
Treatment and Long-term Follow-up - Ongoing Care Management and Support
Care Coordination and Support Services:
Primary Care Specialty Clinical Non-Clinical Task
EMR Integration - Coordinate Electronic Medical Record integration if relevant
Barrier Assessment - Address financial/transportation difficulties, connect to supportive options
Social Work Coordination - Escalate complex social/emotional or economic issues
Brain Health Action Plan - Initiate generalized brain health action plan
Educational Support - Provide patient/caregiver education and connect to local/national resources
Caregiver Assessment - Perform caregiver burden assessment (ex: Zarit scale), escalate to social worker per protocol
Primary Care Coordination - Coordinate with referring Primary Care Provider (PCP) on next steps
Specialist Coordination - Coordinate with specialist staff to ensure appointment adherence
Plan Adherence - Verify patient adherence with generalized brain health action plan
Ongoing Support - Ensure patient and family continue to receive medical, physical, and emotional support
Specialist Triage - Triage patient for appropriate specialist care
Primary Provider Assignment - Identify primary dementia provider for ongoing care oversight
Advanced Treatment Pathway Management:
Primary Care Specialty Clinical Non-Clinical Task
Navigator Transition - Hand-off from BHN to GUIDE navigator for suspected Alzheimer's disease patients
Treatment Education - Educate patient and family on new Alzheimer's Disease Modifying Treatments (DMT) care pathway, risks, and benefits
Genetic Testing - Coordinate genetic testing, when appropriate
Infusion Management - Schedule and track infusions
Infusion Coordination - Manage infusion appointments and treatments
MRI Monitoring - Schedule and track monitoring MRIs
MRI Management - Coordinate ongoing MRI appointments
PET Scan Follow-up - Arrange PET scan if needed for treatment monitoring
Insurance Navigation - Help patient navigate benefits available through insurance
Provider Communication - Maintain ongoing communication with referring providers
Comprehensive Education - Provide relevant patient education throughout treatment
Quality Assurance and Best Practices:
Primary Care Specialty Clinical Non-Clinical Task
Research Integration - Identify and coordinate research opportunities when appropriate
Resource Connection - Connect patients to community resources (Area Agency on Aging, respite services)
Family Support - Ensure ongoing caregiver education and support resources
Documentation Excellence - Maintain comprehensive documentation of all interactions and services
Care Transitions - Ensure smooth transitions between care levels and providers

📊 TOTALS SUMMARY

Primary Care Specialty Clinical Non-Clinical
0 0 0 0

We tallied it all up for you to help determine where and what personnel might be most effective in your health system. If you have not already set your Brain Health Navigator Model (BHN) Care Pathway, now may be a good time to create your BHN Care Pathway and come back to this list once you know more on where and how these line items will be completed. These tools may all be utilized iteratively as your system works through implementation.