Lawful Permanent Residents (LPRs) with disabilities that impede performance on the US Citizenship Exam require a Medical Certification for Disability Exception (Form N-648) to naturalize, usually filled out by their primary care physician (PCP). As many qualifying cognitive and psychiatric diagnoses for the N-648 are difficult to evaluate in primary care, we developed an embedded neuropsychological assessment program to (1) meet the critical need for specialized disability assessment and (2) enable PCPs to identify appropriate tools for N-648 evaluation for suspected cognitive impairment.

This innovation served patients requesting an N-648 evaluation in the primary care clinic of Boston Medical Center’s Immigrant and Refugee Health Center. We formed a consultation group consisting of a PCP, embedded psychologists, consulting neuropsychologists, and an immigration legal navigator and met weekly to discuss clinical cases, outcomes, and adaptations to our processes in line with a Plan-Do-Study-Act (PDSA)1 approach.

During the first 2 years of the innovation, 177 N-648 requests were received by the primary care practice at large. Referrals for brief neuropsychological assessment (n = 34) came from PCPs based on their assessment of the need for further testing.

When the N-648 was sought for cognitive concerns, the referring PCP was first asked to complete a cognitive screener because a positive screening often provides sufficient data to complete an N-648. We implemented a practice-wide recommendation that PCPs screen patients aged ≥50 years with the Rowland Universal Dementia Assessment Scale (RUDAS) to document age-related cognitive impairment. This measure is appropriate for patients with low literacy and education2 and has sensitivity across levels of acculturation and multilingualism.3 Two teaching sessions were held to train PCPs on RUDAS.

When the N-648 was sought for other concerns (eg, complex psychiatric presentation, suspected learning disorder) we accepted referrals directly for neuropsychological assessment. Patients attended 3 appointments (Supplemental Figure): a telemedicine clinical interview, a brief in-person neuropsychological testing session (Supplemental Table), and a feedback session. We concluded by providing a brief report to the referring PCP, a completed N-648 form when indicated, and referrals to appropriate specialty services. The embedded nature of this intervention provided access to typically difficult-to-access services at the patient’s primary medical access point. Since problems with memory, learning, and attention were concerns for many patients, we also built in frequent appointment reminders (eg, telephone calls, secure messages) and support from patient navigators. Our legal navigator linked patients who did not have a qualifying medical condition for the N-648 to supports in preparing for the naturalization exam (eg, community partners that specialized in English literacy and civics exam preparation).

Patients accepted into our program had deficits caused by various conditions such as neurodevelopmental disorders (eg, severe attention deficit/hyperactivity disorder, intellectual disability), major and mild neurocognitive disorders (eg, due to traumatic brain injury), cognitive impairment resulting from other causes (eg, COVID-19 brain fog), and comorbid psychiatric conditions (eg, mild cognitive impairment, post-traumatic stress disorder, major depressive disorder, severe). Of the participants who qualified for an N-648 through our program, 36% had a normal score on initial cognitive screening with their PCP, meaning they would not have received an N-648 that they qualified for without our specialized assessment. Primary care practices with an integrated behavioral health model and an embedded psychologist are well positioned to do this work.