The COVID-19 pandemic had numerous adverse impacts on healthcare systems, and the Veterans Health Administration (VHA) was one among many who had to manage patient safety and quality of care during a crisis (1). Disruptions and delays in access to and utilization of different healthcare services were commonly faced concerns at both the VHA (2) and other healthcare services (3–5). Many services found themselves with an increasing backlog of patients, resulting in numerous challenges including reduced access to care and increased chance of poor patient outcomes [including elevated mortality rates (6)], as well as risk of increased financial burden due to complications related to delayed care (7). Even now, medical systems are struggling to recognize and effectively manage the backlog that accrued during that time (8–10), and the field of neuropsychology is no exception. Neuropsychology as a field took a variety of stances in response to the COVID-19 pandemic including closing clinics, reducing caseloads, or adjusting their clinical practices to include some form of teleneuropsychology (11–13).

Currently, many neuropsychologists face significant patient backlogs that only worsened during the COVID-19 pandemic, which can significantly worsen patient outcomes as delays in identification and treatment of conditions have been associated with negative consequences. Even before the pandemic, delays in diagnosis and treatment were a subject of research for the VHA to determine and address root causes for said delays (14). For neuropsychologists, timely diagnosis of neurodegenerative disorders such as dementia impacts their ability to connect affected individuals with early interventions for potentially slowing progression of the disease which has impacts on both personal and societal levels (15). Early diagnosis and intervention for neurodegenerative disorders results in improved patient adjustment, slower disease progression, economic savings, increased patient independence, and delayed need for nursing home care or hospital admission, demonstrating that timely purveyance of neuropsychological assessment services is essential for optimal patient care (16, 17).

While there has been improvement in awareness of potential risk factors as well as in detection, diagnosis, and potential prevention of dementia, it remains a growing concern as the number of individuals living with dementia is projected to increase to 152 million by 2050 (18). Notably, the prevalence of veterans with dementia is also expected to increase in the coming years (19). Furthermore, research has also highlighted differences in the incidence of dementia in older veterans depending on geographical location, with the highest incidence consistently observed in the Southeast and South, which includes Arkansas (20). Limited access to neuropsychological services, especially in rural areas (21) such as many parts of Arkansas, means that waitlists for providers and clinics can extend for several months or more.

While there was an increase in use of telehealth services for delivery of neurocognitive evaluations (11–13) which can address certain barriers to care, continued use of telehealth for neurocognitive evaluations is highly variable. Telehealth utilization is complicated by concerns related to test validity and security as well as frequent changes in coding/billing for telehealth services (21, 22). Additionally, factors such as access to and comfort with technology (23–25), level of health literacy (26), access to specialized healthcare such as neuropsychology in rural areas (21, 22) have a significant impact on service availability. The pandemic highlighted the importance of addressing barriers such as low digital literacy (27, 28) and attitudes towards use of telemedicine (29) with the hope of continued and increased utilization of these services beyond the necessity of pandemic conditions. However, use of telemedicine alone does not address the growing waitlists many providers may find themselves facing.

Prior research on reducing wait times for neurocognitive evaluations has found success with interventions such as improving scheduling practices, adjusting appointment length, and increasing inter-professional consultation (30). More generalized research on strategies for improving VHA services recommended updating policies and procedures, strengthening communication, and standardization of care to address root causes of delays in diagnosis and treatment (14). Building from that research, another potential way to reduce a clinics' backlog of referrals is through consult management processes which prioritize seeing patients most in need of neurocognitive evaluation services while simultaneously triaging patients whose care could be better addressed by other clinics/providers (31). The purpose of the present quality improvement (QI) project was to create and implement comprehensive criteria to streamline consult management in an interdisciplinary memory disorder clinic at the Central Arkansas Veterans Healthcare System.

Prior to implementation of the QI project, almost all referrals received were accepted under the assumption that the referral met general inclusion criteria (i.e., individuals older than 65 years endorsing memory concerns, no reported active substance abuse). However, these criteria were deemed insufficient by the memory clinic team and new exclusionary criteria were agreed upon with the intention of ensuring more appropriate referrals and improving patient care and experience.

During the implementation phase of the RE-AIM framework, consult reviews were conducted between August 2023 and April 2024 for VA Memory Disorders Clinic. A total of 195 consults were reviewed by members of the memory disorders clinic, including neuropsychologists and geriatric psychiatrist, who conducted chart reviews of the electronic medical record to determine appropriateness for receiving services in the memory disorder clinic based on the new consult exclusionary criteria (see Table 2 for full criteria). Excel spreadsheets were used to record whether each consult met the exclusionary criteria and whether they were appropriate for the memory disorder clinic or should be triaged elsewhere. Approximately 40% of referrals were triaged to other services where their medical and/or mental health needs could be addressed appropriately.

Of referrals that were triaged, nearly 58% were deemed inappropriate for neuropsychological testing and directed to non-assessment-based care such as primary care, social work, neurology and geriatric e-consult. The remaining 42% were referred to outpatient neuropsychology as they required assessments beyond the resources of the memory disorders clinic including individuals deemed too young to be appropriately evaluated by the memory clinic and those primarily requiring a capacity evaluation. Please see flowchart (Figure 3) for additional information on referral management. Consults that contained too little information to make a determination about the best avenue of care for a veteran were addressed by requesting additional clarifying information from the referring providers about the nature of the consult request before being accepted for care by the memory disorder clinic or being triaged elsewhere as necessary.

The 58% of referrals that were triaged elsewhere for care were due to factors including: 1) referral being sent too soon following an acute brain injury/stroke to allow for adequate physical and cognitive recovery, 2) significant untreated mental health difficulties that could confound cognitive testing results, 3) profound evidence of major neurocognitive disorder diagnosis confirmed by prior evaluation already receiving medical treatment including medications, and 4) active/ongoing substance use and abuse which could also complicate patients' diagnostic pictures. At its highest caseload, the memory disorder clinic serviced up to 8 patients a day, in part in an effort to reduce the wait time patients had before accessing care. However, this approach was untenable as it drastically limited the time the team could allocate to each patient, thus potentially reducing the quality of their care. With improved consult management, the clinic has been able to reduce its caseload to 4 patients a day which has allowed for more comprehensive evaluation by neuropsychology, social work, geriatrics, and geriatric psychiatry, thus improving patient care.

Prior to this reduction in caseload, all patients in the memory disorders clinic were provided cognitive screenings by neuropsychology as well as a diagnostic interview including medication considerations by a geriatric psychiatrist or geriatrician. However, due to staffing limitations, typically only around 4 patients per day were able to be provided with social work services. The patients seen by social work were prioritized by level of need based on record review. A pharmacist was of limited on call availability due to staffing restrictions as well and was only utilized in cases where significant polypharmacy concerns were present.

By reducing the caseload via improved consult management criteria, numerous improvements in clinical care have occurred. Neuropsychology was able to provide more comprehensive testing batteries, allowing for improved diagnostic utility and more personalized treatment recommendations. Social work gained the ability to meet with and offer services to every memory disorder clinic patient due to the lower caseload. Geriatric medicine and geriatric psychiatry were able to increase the amount of time spent with patients and caregivers during their appointment, improving overall patient experience. Additionally, pharmacy could now assist with medication management for the reduced caseload rather than only in cases of polypharmacy concerns.

The memory clinic team also provided in-services to providers, ranging from sharing information in staff meetings to individual meetings with providers making frequent referrals, to educate them on the various roles and functions of the memory clinic to include the limits of care that could be provided in this setting. We utilized the GRECC “Education Bursts” model that provides brief educational material over several convenient locations and times such as in regularly scheduled staff meetings, and between patient visits for busy outpatient providers (35). Despite these educational efforts, there were a few providers who expressed additional concerns with consults being triaged and contacted the memory clinic team directly to request additional consideration of a patient for whom an evaluation was requested; infrequently patients were rebooked in the clinic after further discussions with referring providers helped elucidate the reason they were referred and how the clinic could best address their care needs.

As part of the intervention, the memory disorder clinic advocated to facility leadership for designation of a permanent MSA for the clinic from the medical center which resulted in assignment of a permanent MSA. Additionally, if needed, a memory clinic provider spoke with patients via phone call to allay anxiety or provide service recovery as needed.

Consult tracking, including compiling information about consultation receipt and completion dates, showed the clinic's waitlist was initially reduced from approximately 6 months to 3 months. With consistent implementation of new consult management criteria via chart review of each new consult, the clinic's waitlist was further reduced to less than a month from initial referral to consult completion. Owing to the increased contact with the MSA and judicious reallotment to other clinical services, longitudinal data collected via normal clinic tracking showed fewer appointment cancellations and no-shows which further increased the clinic utilization metrics. Verbal feedback received from the patients evaluated in the memory clinic was positive as well, with many patients expressing appreciation for short clinic wait times and improved communication with the team throughout the scheduling and assessment process. Discussion among memory clinic team members at monthly staff meetings indicated they generally felt that they were able to provide better care for the patients with this updated model as well due to a reduced caseload that allowed for greater time to be spent with patients.

Like many clinics providing a specialty service, the CAVHS memory disorder clinic developed a significant backlog due to multiple factors. Due to limited resources, the clinic is only offered one day a week. The PACT act, which expanded healthcare eligibility for veterans with presumed toxic exposures (36), led to a significant influx of patients seeking services from an already heavily utilized clinic. Additionally, the MISSION act created a veterans community care program (37) which allows them to seek care outside of the VA in an effort to increase access to timely care. However, since the memory disorders clinic is a highly specialized service, community care options were limited and those few options that were available often had similar or longer wait times. When Covid-19 guidelines suspended in-person evaluations for a significant amount of time, the waitlist grew further to approximately six months in 2023.

From a patient perspective, individuals were experiencing long wait times for care and, if rescheduling was necessary, access to care was delayed further due to the length of the waitlist. Patients who requested scheduling within a certain time frame were sometimes unable to be accommodated due to lack of clinic availability due to patient volume. Family and caregivers had to seek alternative services for dealing with loved ones experiencing worsening cognition and accompanying neuropsychiatric symptoms or attempt to manage on their own until their long-awaited appointment. To provide services to veterans and their families how and when they most needed them (i.e., “right care at the right time”), adjustments had to be made to the existing memory disorder clinic consult management process to ensure assess to timely and appropriate care.

Our QI project proved that by appropriately managing referrals and reducing the waitlist, there is an improvement in our ability to provide patients with timely, high-quality care that can most effectively address their needs based on our clinic's capabilities. A reduced waitlist has the potential to improve overall patient experience as they are getting more expedient access to care by being scheduled in the memory disorder clinic or quickly allowing their referring provider to revise their referral to more appropriately address their needs rather than having to do so after waiting potentially months for an appointment in a clinic that was incapable of doing so. By implementing this new consult management criteria into normal clinical practice via chart review of each incoming consult, this intervention has continued to be maintained as part of standard operating procedures.

The combination of RE-AIM framework and elements of PRISM provided a scaffolding for development and implementation of an intervention utilizing improved consult management criteria. Analysis of the areas of need from both an organizational and patient perspective provided multiple avenues for improvement. Implementation of consult management criteria, combined with thorough chart reviews and providing psychoeducation to referring providers, resulted in a substantial waitlist reduction, thus providing expedient access to care for patients most in need of memory clinic services while also directing patients deemed inappropriate for memory clinic care to services that could better address their needs. Giving education to providers regarding the capabilities of the memory disorder clinic and providing consistent feedback regarding the rationale for declining consults and linking these decisions to specific inclusion criteria aided in the adoption and maintenance of the new consult management criteria. Providing information on what patients the memory disorder clinic could best serve (as well as those who might benefit most from other services) empowered referring providers by giving them the opportunity to pre-emptively decide whether a consult was more appropriate for another service prior to initial review by the memory disorder clinic team, thus preventing service over-utilization.

Establishing comprehensive criteria allows neuropsychologists to manage consults in a way that prioritizes patients most in need of their services while also triaging patients more appropriate for other services. Overall, this QI project demonstrated how implementation of consult management criteria in a memory disorders clinic greatly reduced the waitlist, thus providing expedient access to care for Veterans with cognitive difficulties and their families/caregivers.