Isaac Health partnered with a regional Medicare Advantage (MA) and Dual Eligible Special Needs (D-SNP) plan to address a growing challenge in its rural member population: low rates of brain health diagnoses, limited access to specialty care, and extremely low digital connectivity. Only 15% of members had reliable internet access, creating a major barrier to early diagnosis and ongoing care.
Despite actuarial forecasts showing a significant prevalence of cognitive impairment and dementia in its member base, the plan had historically identified only about half of the expected cases. The result was missed opportunities for early intervention and higher downstream medical costs.
To close the gap, Isaac Health worked with the plan to implement a rapid, cost-effective brain health program tailored to rural access needs. Within three weeks, Isaac Health launched a proactive outreach and assessment strategy designed to find members at highest risk, confirm diagnosis, and connect them into longitudinal care.
A low-barrier model for diagnosing cognitive impairment
The program began with Isaac’s two-step screening approach, which minimizes friction for both the plan and its members:
- Data-driven risk identification using claims and health record insights to target members with the greatest likelihood of impairment.
- A five-minute phone-based screening, allowing members to complete an initial assessment without a device, internet connection, or travel.
Members identified as high-risk received a comprehensive diagnostic evaluation, including cognitive testing, treatment planning, and access to Isaac Health’s ongoing care management model. Because most members could not reliably access telehealth services on their own, Isaac Health provided in-home facilitation for virtual visits, ensuring that every eligible member could complete their evaluation and receive specialty support, regardless of their internet connectivity.
Measurable impact
The early success of the program led the plan to expand the model beyond dementia to include other brain health conditions, recognizing the importance of early detection and proactive care for neurological and cognitive disorders in older adults. The partnership demonstrated improved outcomes as well as a strong financial return for the plan. Key results include:
- 4x ROI based on reduced acute care utilization and improved member management
- 55% increase in documented diagnosis rate compared to baseline
- 40% enrollment among members identified as eligible
- 74% member engagement maintained at six months
- 38% reduction in emergency department admissions vs. a control group
- 28% reduction in hospital days vs. a control group
These results show that even in highly rural, low-connectivity populations, a targeted, virtual-first brain health program can improve diagnostic accuracy, increase member engagement, and reduce avoidable utilization costs. With the right approach, access barriers do not have to limit access to specialty brain health care.