Scaling Alzheimer’s Care: The Case for Specialized Treatment Clinics

Abstract

Background:

The approval of amyloid-targeting monoclonal antibodies has transformed Alzheimer’s disease (AD) treatment, shifting the field from symptomatic management to targeting the underlying pathology. These therapies require specialized care models to manage the selection, treatment, and monitoring of eligible patients.

Methods:

Here we describe the implementation of the Anti-Amyloid Treatment Clinic (KU-AATC) at the University of Kansas Health System, a dedicated clinic model designed to streamline access to amyloid-clearing therapies and to provide safe, efficient patient care. We detail the KU-AATC’s structured approach, including a multidisciplinary team with advanced practice providers (APPs) leading patient evaluation and shared decision-making, and tailored workflows to ensure timely access to treatment. We review data from the clinic’s first 18 months.

Results:

The KU-AATC model demonstrates a feasible approach to managing the complex needs of amyloid-targeting therapy for AD.

Conclusions:

Our findings suggest that a specialized clinic structure can support safe, accessible, and efficient care for AD patients, potentially serving as a scalable model for healthcare systems adapting to the demands of emerging AD treatments. Expanding similar clinics may address neurologist shortages and improve equitable access to advanced therapies.

INTRODUCTION

The landscape of Alzheimer’s disease (AD) treatment is undergoing a significant transformation with the recent approval of amyloid-targeting monoclonal antibody therapies.^1,2 These treatments, including lecanemab, donanemab, and aducanumab, modify the underlying pathology of AD rather than managing symptoms.^3,4 However, their approval creates an urgent need to innovate how these therapies are delivered. Traditional memory care and neurology clinics, long structured around generalized care models, are not equipped to handle an increasing number of patients who will qualify for these highly specialized and resource-intensive therapies.^5–8 Scaling the current system to meet this demand is impractical without rethinking the core structure of AD care.^9,10

Delivering these new therapies requires much more than simply increasing clinic capacity. It demands a multidisciplinary, highly specialized team to efficiently manage the critical tasks of selecting appropriate patients, engaging in shared decision-making, prescribing treatments, and closely monitoring for adverse events.¹¹ Amyloid-related imaging abnormalities (ARIA), such as microhemorrhages and cerebral edema, require ongoing MRI surveillance, adding complexity and burden to the healthcare team. The combination of these factors necessitates a dedicated clinic model, where the specialized team can manage these tasks, empowering primary care providers and other specialists to screen and facilitate early therapy or refer their patients for focused care.^12,13

Currently, there are few clinics across the U.S. with the infrastructure to administer these amyloid-targeting therapies. Existing reports and anecdotal evidence suggest that centralized coordination, financial sustainability assessments, and integration of electronic medical record (EMR) tools are critical for successful implementation.¹³ However, these reports are limited, and there is a need for more detailed descriptions of how different health care environments are adapting to this new era in AD treatment.

The University of Kansas Health System (TUKHS) established its Anti-Amyloid Treatment Clinic (KU-AATC), a specialized clinic dedicated to streamlining access to amyloid-clearing therapies, in mid-2023. The goal has been to fast-track access to amyloid monoclonal antibody drugs, ensuring these are an appropriate option for patients with AD and their families, and, if so, managing the prescription and safety monitoring required to safely give the drug. The importance of fast-tracking access is the need to buffer the impact these drugs may have on clinic wait times, which has been estimated to grow to more than 4 years by 2027, mostly due to the scarcity of AD specialists and PET scanners.¹⁴ This paper aims to describe the implementation of the KU-AATC during its first year, offering insight into how focused care models can address the emerging demands of AD treatment.

METHODS

Description of the Clinic:

TUKHS is a comprehensive regional, academic medical center. The TUKHS Department of Neurology Memory Care Clinic has served as a tertiary referral clinic for AD and related disorders since 2004. In 2023, the Memory Care Clinic supported the care of 2,891 unique patients. With the approval of lecanemab, the Memory Care Clinic, recognized a need for creating treatment capacity to accommodate the expected demand. Others have described steps for onboarding new therapeutic models¹³ which are likely to vary by system. Here, we focus on the structured processes of the KU-AATC, designed to ensure efficient patient flow and comprehensive care management..

Between July 2023 and January 2025, the KU-AATC has received 308 patient referrals, with 93 individuals (34%) excluded due to safety concerns or personal decisions to forgo treatment. An additional 73 patients remain in various stages of evaluation or treatment decision-making. Of those pursuing therapy, 130 patients have initiated the treatment process, including 100 actively receiving therapy and 22 awaiting treatment initiation. Figure 1 provides a complete CONSORT-style diagram of patients in each stage of evaluation and treatment. Data were collected under a quality assurance project approval (KUMC Institutional Review Board) and may not be generalizable to other clinical experiences.

Figure 1:

CONSORT-style Diagram of Patient Flow

Clinic Team:

The (KU-AATC) clinical team is currently composed of a board-certified neurologist, an advanced practice provider (APP), a neuropsychologist, a psychometrist, two nurses, and a clinic manager, each contributing varying levels of effort to the clinic’s operations (see Table 1). The neurologist provides overall clinic oversight, supervises patient care, manages e-consults, and oversees the treatment of adverse events. The APP, trained in dementia evaluation and appropriate use guidelines for monoclonal antibody therapy, serves as the clinical backbone of the clinic, performing initial evaluations, assessing eligibility, guiding shared decision-making, and monitoring patient safety. A neuropsychologist provides oversight for cognitive testing, when necessary, and interprets the test battery, while a psychometrist administers these tests under the neuropsychologist’s supervision. The clinic manager ensures efficient operations by overseeing staffing and administrative tasks. Finally, nurses play a crucial role in providing navigation services and coordinating patient care, including visit scheduling, planning and tracking infusions and surveillance MRIs, and managing data entry for the CMS Registry.

Table 1.

KU Anti-Amyloid Therapy Clinic Staffing

Role	Credentials	Responsibilities	Effort
Physician	Clinic physicians are board certified neurologists.	Overall supervision of clinical care; e-Consults for all patients moving on to therapy; Sign treatment plan orders; Oversee management of adverse events	2h/week
APP	Current staff are Advanced Practice Registered Nurses or FNP, though we remain open to all appropriate advance practice provider credentials willing to complete the cognitive disorders fellowship.	Perform initial visits and complete work up; Assess eligibility; Guide shared decision making; Discuss Monitor safety with patients.	20h/week
Neuropsychologist	Neuropsychologists are doctorally trained, licensed clinical pychologists.	Oversee and interprets cognitive test battery	2h/week
Psychometrist	Certificiation by the overseeing neuropsychologist	Performs cognitive testing battery	6h/week
Clinic manager	Appropriate experience. Currently, the clinic manager is a registered nurse.	Oversee staffing	4h/week
Nurse navigator	Current staff are registered nurses.	All visit scheduling; Planning and tracking infusion and surveillance MRI visits; Data entry for CMS Registry	2 at 30h/week

Referral Process:

Patients are referred by primary care physicians, geriatricians, and general neurologists, both within and outside TUKHS. Table 2 provides a general descriptive overview of participants evaluated and treated in the KU-AATC clinic. Any referrals to the Memory Care Clinic, of which the KU-AATC is part, require that we have clinical notes from the referring physician detailing the nature of the cognitive issues and that the clinician has completed at minimum bedside cognitive testing or more in depth neuropsychological testing. We also require that an MRI have been completed in the last year and the referral is accompanied by the MRI report. In the initial months of the clinic, we experiemented with requiring confirmation of cerebral amyloid and ApoE testing but this proved to be a major barrier given the referring providers’ difficulty ordering these tests and with reimbursement issues.

Table 2.

Patient Demographics

	All Referrals (n =308)	Treated (n=111)
Age	74.1 (7.4)	73.5 (6.9)
Female	172 (56%)	66 (59%)
Race
White	285 (93%)	108 (97%)
Black/African American	6 (2%)	1 (1%)
Asian	2 (1%)	1 (1%)
Another Race Identity	15 (5%)	1 (1%)
Hispanic or Latino Identity	3 (1%)	1 (1%)
Rural Dwelling	45 (15%)	15 (14%)
Initial STMS Score, median [range]	28 [13–37]	27 [16–37]
Initial FAQ Score	6 [0–27]	6 [0–27]

Age is given as mean years (standard deviation). Sex, Race, Hispanic ethnicity, and Rural Dwelling is given as n (%). Rural dwelling is based on residential ZIP code consistent with Federal Office of Rural Health Policy classification. Short Test of Mental Status (STMS) and Functional Activities Questionnaire (FAQ) are given as median [range]. STMS scores are out of 38 total points, with higher scores indicating better performance. FAQ scores are out of a possible 30 points, with higher scores indicated worse function.

Initial Visit and Workup:

Patients and their families attend an initial consultation with the APP. This visit includes a comprehensive discussion of anti-amyloid therapies, covering risks, benefits, and the treatment logistics. The APP uses a standardized handout to structure this conversation (Supplemental File 1), addressing treatment expectations, potential benefits, potential costs, risk evaluation, and potential burdens. The APP reviews for inclusion and exclusion criteria in line with appropriate use guidelines.¹⁵ The visit is documented using a standardized template in the medical record (Supplemental File 2).

During the initial consultation, the APP orders any remaining diagnostic procedures to assist with determining eligibility for anti-amyloid therapy, including cognitive testing, MRI with heme sensitive sequences, lumbar puncture or amyloid PET to confirm the presence of cerebral amyloid, and APOE genotyping. Lumbar puncture for AD biomarker testing is currently preferred (to acquire information on both amyloid and tau levels) though PET imaging is also used based on patient preference or when lumbar puncture results are indeterminate. The APP schedules a follow up appointment in 1 to 3 months to review the results and discuss treatment options. The nurse navigators track the completion of these remaing tests and as needed help coordinate these by working with patients to ensure they are completed prior to the follow up visit.

Neuropsychological Testing:

If cognitive testing is incomplete to assess the stage (i.e. MCI or mild dementia), we have developed a streamlined process for more in depth neuropsychological testing. Traditional neuropsychological evaluations often lead to delays in care due to extended wait times, which can postpone treatment for Alzheimer’s patients by several months. To address this issue, an abbreviated cognitive testing visit was developed. The visit employs brief cognitive testing, including the Short Test of Mental Status (STMS)¹⁶ and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS),¹⁷ to efficiently evaluate cognitive functioning and establish a baseline. To assess current symptoms and functional status, questionnaires including the Functional Activities Questionnaire (FAQ)¹⁸ and Everyday Cognition Questionnaire¹⁹ are completed by the patient’s family member or care provider while the patient is testing. This streamlined approach significantly reduces wait times for patients, which would otherwise be delayed by referral for full neuropsychological assessment. This procedure was also designed to be repeatable with longitudinal follow-up for continuous monitoring of cognitive status as well as outcomes measurement. It should also be noted that the cognitive testing visit often coincides with the initial visit, depending on provider availability, in order to reduce travel demands on patients.

Follow-up Visit:

After completing all diagnostic procedures, the patient returns for a follow-up visit with the APP. During this visit, test results and treatment options are reviewed in a shared decision-making process, considering both eligibility and whether the therapy aligns with the patient’s goals. The APP, patient, and care partners discuss the benefits, risks, treatment burden, and time commitment, setting realistic expectations. A candid discussion of personal factors—such as risk tolerance, lifestyle, and financial considerations—helps guide the decision. If anti-amyloid therapy is chosen, enrollment in the CMS registry is initiated.

e-Consult:

When a patient opts to proceed with therapy, the APP submits an electronic consultation (e-Consult) to the clinic medical director for review. An e-Consult is an asynchronous, interprofessional communication that allows specialists to provide clinical guidance without requiring a face-to-face visit. This consultation system ensures that the supervising physician assesses diagnostic data and evaluates treatment risks and benefits, which maintains the quality of care while allowing the medical director to focus on complex cases. This model streamlines physician oversight without necessitating direct patient contact for each case, thus optimizing care coordination.

Treatment Initiation:

Once the medical director approves the evaluation and treatment orders, the nurse navigator creates a schedule of infusions and intervening surveillance MRI scans at appropriate intervals. The nurse navigator works with the infusion center to secure prior authorization and registers the patient in the mandatory CMS registry, entering all requisite information, including required data such as the initial cognitive test (in our case the STMS) and FAQ scores.

Our team coordinates with TUKHS Infusion Center and, more recently outside infusion centers, to ensure the initial infusions include an extended post-infusion observation period. Critical to success has been the support of the broader health system infrastructure. The health system prior authorization team plays a crucial role in addressing insurance denials and ensuring patients can access treatment. Their expertise and collaboration are integral to the success of the clinic’s operations. Also, TUKHS Infusion Center provides centralized infusion services for patients receiving monoclonal antibody therapy. The team has expertise in optimal scheduling, dosing, post-infusion care and monitoring that our clinic had, until recently, limited experience with.

To support our extensive catchment area, we collaborate with other infusion centers across Kansas to ensure they are prepared to follow the observation protocols and communicate information on completed infusions to our centralized system for consistent oversight. However, many centers are unprepared to facilitate post-infusion observation beyond 30 minutes, so we generally recommend the first three infusions occur in our infusion center. Of the 100 total actively treated patients, we are currently treating 86 within the KU system and 14 outside our health system.

MRI Monitoring:

Monitoring for Amyloid-Related Imaging Abnormalities (ARIA) is critical for patient safety. The clinical navigator tracks infusions and completion of MRIs and maintains regular contact with patients to ensure they schedule their MRIs. Once the navigator places the MRI order, patients and their families are responsible for finalizing the appointment, with the MRI scheduled within a 10-day window centered between infusion intervals. For lecanemab, MRI scans are required after the second, third, and sixth infusions, with additional scans as necessary. The clinical navigator tracks these MRIs and stays in contact with patients to confirm timely completion, and both Radiology and the APP review each MRI before the next infusion.

While patients have the option to choose their preferred MRI site, we recommend using our health system’s MRI center to ensure that scans are conducted and interpreted accurately. We also collaborate with external imaging centers for baseline and monitoring MRIs. Proper training and orientation to these new therapies is a critical component of onboarding. Prior to engaging with these centers, we meet with their radiology teams to ensure they understand proper use of heme-sensitive sequences and have appropriate radiological training for detecting ARIA. These steps ensure high-quality imaging and consistency in patient monitoring across different locations.

Follow-Up Visits:

Follow-up visits with the APP occur at 6, 12, and 18 months to monitor cognitive function and address any emerging adverse effects. During these visits we adminster STMS and FAQ tests both for monitoring treatment and CMS reporting. If patients are experiencing significant cognitive decline, adverse effects or burden, or expresses concern about treatment benefit we discuss discontinuing treatment. Our current approach is to treat for a full 18 months for both lecanemab and donanemab. After 12 months of therapy, we begin discussing options for therapy following the 18 months of treatment duration. At this time we will schedule an amyloid PET to be completed after 18 months of therapy (or CSF if amyloid PET cannot be obtained). This is done to provide us with information as to whether amyloid levels have normalized to help determined if we hold infusions or continue with maintenance dosing. We expect this approach to evolve considerably as more long term data is available to inform this approach.

Handling Adverse Events:

As of January 2025 we have had 8 cases of ARIA, seven of whom were apoE4 carriers (n=3 homozygotes). Only one case of ARIA was symptomatic (headaches) and 4 patients discontinued treatment due to ARIA. Another patient’s monitoring MRI revealed superficial siderosis that had been present but not identified on the initial baseline scan. After discussion, the patient and family chose to discontinue therapy.

We have structured protocols in place to address ARIA or other adverse events. We follow Appropriate Use Guidelines for defining the severity of the ARIA and for making clinical decisions to hold or stop therapy. Infusions are immediately halted for patients showing significant ARIA pending further review. Patients who exhibit ARIA receive close monitoring with additional MRI scans and neurological assessments as needed. In cases where treatment modifications are required, the APP collaborates with the medical director to determine the appropriate course of action based on the severity and presentation of symptoms.

Treatment Exclusions:

Of the 308 patients referred to the AATC, 93 (34%) have been excluded due to safety concerns or personal decisions not to pursue treatment. An additional 73 patients are in various stages of evaluation or treatment decision-making. Of those treated, 9 have discontinued – four for ARIA, 1 for superficial siderosis found retrospectively on baseline MRI, and four others due to logistical burden, headaches, cochlear implant, and personal reasons. For those opting out of anti-amyloid therapy, our clinic provides standard-of-care dementia treatment through the Memory Care Clinic, staffed by dementia-focused clinicians. We have also developed a comprehensive psychosocial support program and a lifestyle education initiative.

Beyond Anti-Amyloid Therapy:

The Memory Care clinic offers care programs beyond anti-amyloid therapy to provide ongoing support of patients. The Cognitive Care Network was established by the KU Alzheimer’s Disease Research Center in 2018 to enhance dementia care by integrating Social Work Navigators who connect patients with essential resources. Embedded within our memory clinic, these navigators provide immediate and ongoing support post-diagnosis, assisting with care coordination and acting as liaisons between patients, families, and healthcare providers. Their role is critical in ensuring individuals receive tailored, comprehensive support.

The LEAP! program is designed to promote brain health for a broad audience, including individuals with normal cognition, those with early-stage dementia or mild cognitive impairment (MCI), and their care partners. Clinicians can refer patients to LEAP! through the electronic medical record system, after which the LEAP! team contacts the patient or care partner for enrollment. Participation in the program also connects patients to the KU Alzheimer’s Disease Research Center’s network of resources, events, research opportunities, and brain health education. During visits, providers share the Simple Steps to Better Brain Health booklet, which includes key brain health strategies and information on program offerings.

DISCUSSION

As we look to the future of AD care, innovative models like the KU-AATC Clinic will be critical in addressing the rising demand for amyloid-targeted therapies particularly within the aging population served by family medicine, geriatrics, and neurology practices. Traditional specialty clinics will not suffice. A dedicated, focused approach is required to streamline treatment and ensure the intensive monitoring needed for these high-risk drugs. Early results from the KU-AATC demonstrate the feasibility of this model, but expansion will be necessary to meet growing patient demand, especially in rural areas. Successful dementia care, especially in underserved rural areas, wil be dependent on effective collaboration between primary care and specialists.²⁰ New biomarkers, including blood-based diagnostics, offer potential to further optimize these processes and reduce wait times, ensuring that more patients receive timely, effective care.

Central to enhancing the efficiency and effectiveness of AD care is the adoption of new biomarkers, including advanced blood-based diagnostics and imaging. Use of these tools continues to rapidly evolve. We expect blood based biomarkers to rapidly change how we screen and select patients for anti-amyloid therapy.²¹ Additionally, including an assessment of brain tau levels may soon be helpful in guiding treatment decisions given data suggesting those with low levels preferentially benefit from anti-amyloid therapies²² though access and reimbursement issues constrain clinical use of tau PET imaging.

As with many regions, the State of Kansas, where the KU-AATC is located, has an insufficient number of neurologists to cover the demand for services.^23,24 Kansas is considered a “neurology desert”²⁵ requiring the KU-AATC to structure itself in a manner that does not depend wholly on physician coverage. The Memory Care Clinic has invested heavily in the professional development and training of APPs (i.e., nurse practitioners or physician assistants), including establishing an APP Brain Health Fellowship, among the first in the US.²⁶ The APP training model has been a cornerstone of the KU-AATC’s success. Developed collaboratively by the KU Alzheimer’s Disease Research Center and KU School of Nursing, the six-month fellowship enhances APP proficiency in diagnosing and managing AD/ADRD. Guided by an expert panel, the curriculum includes modules on treatment strategies, neuropsychology, neuroimaging, biomarkers, social work, end-of-life care, and research. The program features weekly didactics, precepted rotations, mentored clinics, and specialized care settings. Fellows receive ongoing evaluations, complete pre- and post-program assessments, and are supported with a competitive salary, laptop, and educational resources.

The KU-AATC provides a structured, multidisciplinary approach to patient evaluation, treatment initiation, and ongoing monitoring, offering a model that can be adapted to other settings. A dedicated, specialized clinic like the KU-AATC also enables continuous refinement and evolution of care based on emerging evidence and advances in monitoring and treatment. For instance, as new methods for assessing therapy response, such as blood-based biomarkers, become available, our structured clinic model allows for more rapid integration of these innovations into practice. Similarly, as our understanding of long-term treatment strategies develops, we can quickly adapt protocols to optimize patient outcomes. This flexibility ensures that care remains evidence-based, proactive, and responsive to the evolving landscape of Alzheimer’s treatment, ultimately improving both safety and efficacy for patients.

While this report details the clinic’s implementation and operations, a comprehensive analysis of financial sustainability, viability, and institutional commitment is still needed and best conducted with a larger patient cohort. Reimbursement models remain in flux, and their adequacy in supporting the growing demand for anti-amyloid treatments is uncertain. Additionally, the financial feasibility of this model will likely vary by healthcare system, geography, and patient population. These factors highlight the need for continued research into the economic and logistical challenges of scaling specialized treatment clinics across diverse healthcare settings.

Dedicated anti-amyloid therapy clinics, with a strong foundation in geriatrics and cognitive neurology, provide an efficient way to manage the selection, prescription, and monitoring processes, allowing primary care physicians, geriatricians, physicians and general neurologists or psychiatrists to refer patients to a specialized setting equipped to handle these complex treatments, or when appropriately equipped and trained, support service lines themselves. By centralizing expertise and incorporating innovative tools like the abbreviated cognitive testing visit, these clinics can streamline care delivery and improve access. This model not only reduces the burden on other healthcare providers but also maintains high standards of care by optimizing clinic operations for safe and precise treatment administration. As the field of Alzheimer’s treatment evolves, expanding similar clinics, particularly in underserved areas, will be essential for reducing wait times and ensuring equitable access to new therapies. Such models provide a scalable blueprint, guiding future clinic development to meet the growing needs of Alzheimer’s patients and their families.

Supplementary Material

Supinfo

Supplementary File 1: KU Accelerated Anti-Amyloid Clinic Treatment Information Sheet

Supplementary File 2: Visit Note Outline and Billing Approach for Accelerated Anti-Amyloid Clinic

Key Points:

• The KU-AATC model addresses the need for specialized care to manage the complexities of amyloid-targeting therapies in Alzheimer’s disease.

• Multidisciplinary teams, including advanced practice providers, ensure efficient patient evaluation, treatment, and monitoring.

• This clinic model can serve as a scalable solution for healthcare systems adapting to the demands of new AD treatments in a variety of specialty settings.

Why does this paper matter?

This paper outlines a feasible, specialized clinic model for delivering amyloid-targeting therapies in Alzheimer’s care, demonstrating how structured multidisciplinary teams can improve access to complex therapies and support safe and efficient patient management.