Beyond the Referral: Preventing Diabetes-Related Vision Loss through Care Coordination

 

Practice Transformation Institute (PTI) is a leading provider of continuing medical education and experiential learning programs for Patient-Centered Medical Homes and other care transformation initiatives.  PTI offers programs and to empower physicians, practice teams, and others in care delivery systems to improve care and outcomes. Each month, PTI offers a brief blog or article addressing a specific practice need or relevant population. For more information or to suggest future topics of interest, please contact PTI at (248) 475-4736 or email info@transformcoach.org.

 

Diabetes management involves more than controlling blood glucose. Preventing complications is equally important, and diabetic retinopathy is among the most serious. As we recognize National Diabetes Month, primary care practices can examine how effectively they identify patients who need retinal examinations, ensure those examinations are completed, and follow up on the results.

Care team members such as Medical Assistants (Mas) and Community Health Workers (CHWs) can play an important role by helping patients overcome barriers to care and strengthening communication between primary care practices and eye care specialists.

Diabetic Retinopathy: The Importance of Early Detection

Diabetic retinopathy is a leading cause of vision loss and blindness in the United States. Because early stages often have no symptoms, routine retinal examinations are essential.

Early detection and appropriate treatment can prevent or delay vision loss. The American Diabetes Association (ADA, 2025) recommends retinal examinations beginning at diagnosis for adults with type 2 diabetes and within five years of diagnosis for adults with type 1 diabetes. Follow-up intervals depend on clinical findings and individual risk.

The Primary Care Challenge: Closing the Referral Loop

Primary care practices routinely identify patients due for retinal examinations and refer them to ophthalmologists or optometrists. However, a completed referral is not a closed referral.  Ensuring referrals result in completed examinations and appropriate follow-up can be challenging.

Patients may face barriers related to scheduling, transportation, insurance coverage, or understanding the importance of an examination when they have no symptoms. Even when examinations are completed, reports may not reach the primary care practice, leaving the care team without information needed to determine appropriate follow-up.

Closing the referral loop requires confirming that examinations are completed, results are received, and recommended follow-up occurs.

Where Care Team Members Add Value

MAs and CHWs are well positioned to support this process as members of the primary care team. Their involvement can begin before the referral and continue through examination and follow-up.

MAs and CHWs can educate patients about diabetic retinopathy, assist with scheduling and transportation, address insurance and language barriers, and reinforce the importance of routine examinations. After referral, they can confirm appointments, contact patients who miss visits, and help reschedule.

After examinations, MAs and CHWs can help obtain reports from eye care professionals and ensure they reach the appropriate clinical team member. When additional evaluation or treatment is recommended, CHWs can coordinate appointments and address barriers that might delay care.

Portable retina cameras offer primary care practices a way to provide point-of-care retinal screening, providing access to diabetic retinal exams and prevention vision loss in patients with diabetes. These portable units allow trained practice staff, including nurses and medical assistants, to capture scans in about one minute. Screening capability includes diabetic retinopathy, glaucoma, and other vascular conditions without needing an immediate specialty care referral. Practices may find this is efficient and cost-effective to close care gaps. 

These responsibilities do not replace clinical assessment or decision-making. Rather, they support physicians, nurses, and care managers by helping ensure services are completed and information is available to guide care.

Implications for Quality and Value-Based Care

Diabetic retinal examinations are included in several major quality reporting and value-based payment programs.

Medicare Advantage Star Ratings. The Diabetes Care – Eye Exam measure assesses the percentage of eligible Medicare Advantage members with diabetes who receive recommended retinal examinations. This measure contributes to Medicare Advantage Star Ratings and may influence financial incentives for participating primary care practices.

Merit-Based Incentive Payment System (MIPS). CMS Quality Measure #117, Diabetes Eye Exam, evaluates appropriate retinal examinations among eligible patients with diabetes. MIPS also includes Measure #19, Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care, which addresses communication of retinal findings to the physician managing the patient's diabetes. Although eye care specialists generally report this measure, it reinforces the importance of communication between specialists and primary care.

Medicaid and Commercial Health Plans. The HEDIS® Eye Exam for Patients with Diabetes (EED) measure is used in health plan quality reporting and may be incorporated into Medicaid managed care and commercial payer incentive programs. Michigan primary care practices participating in payer-sponsored quality improvement and value-based arrangements may also have diabetic retinal screening included in their performance measures.

For primary care practices, this creates both clinical and operational concerns. Patients may have completed their examinations, but missing reports or incomplete documentation can prevent those services from being reflected in quality performance.

MAs and CHWs can help close this gap through patient outreach, referral tracking, and communication with specialty providers, improving documentation and reducing administrative demands on clinical staff.

Making the Process Work in Primary Care

Integrating MAs and CHWs into diabetic retinal screening and follow-up does not necessarily require new infrastructure. Practices can use existing electronic health records, patient registries, and care gap reports to identify patients overdue for examinations.

An effective workflow identifies patients needing examinations, assigns outreach and referral responsibilities, and tracks receipt of results. Incorporating standing orders so MAs and CHWs can support these activities is efficient and allows clinicians review findings and determine next steps.

Clearly defined responsibilities and communication pathways are essential. MAs and CHWs  need to know when and how to escalate concerns, particularly when patients report new vision changes, experience difficulty obtaining specialty care, or require additional assistance.

For practices with limited care management resources, integrating MAs and CHWs  into this process can expand care team capacity and improve coordination without adding to the clinical workload.

Moving Beyond the Referral

Preventing avoidable vision loss requires more than identifying patients who need retinal examinations. It requires coordinated care that ensures examinations are completed, findings are communicated, and recommended follow-up occurs.

Integrating MAs and CHWs into this process strengthens primary care's ability to prevent complications, improve quality performance, and make more effective use of care team resources. National Diabetes Month offers an opportunity to look beyond whether referrals are made and consider what happens afterward.

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References

American Diabetes Association Professional Practice Committee. (2025). Retinopathy, neuropathy, and foot care: Standards of care in diabetes—2025. Diabetes Care, 48(Supplement 1), S252–S265.

Centers for Medicare & Medicaid Services. (2026). 2027 Medicare Advantage Star Ratings fact sheet.

Centers for Medicare & Medicaid Services. (2025). 2026 Quality Measures (117, 19). Measures and Activities - QPP.

National Committee for Quality Assurance. (2026). HEDIS® measure description: Eye exam for patients with diabetes.

 

Suicide Prevention in Older Adults: Adding Dementia to the Conversation

 

Practice Transformation Institute (PTI) is a leading provider of continuing medical education and experiential learning programs for Patient-Centered Medical Homes and other care transformation initiatives.  PTI offers programs and to empower physicians, practice teams, and others in care delivery systems to improve care and outcomes. Each month, PTI offers a brief blog or article addressing a specific practice need or relevant population. For more information or to suggest future topics of interest, please contact PTI at (248) 475-4736 or email info@transformcoach.org.

 

This month, we address suicide prevention in older adults.

Suicide Prevention in Older Adults: Adding Dementia to the Conversation

Suicide prevention is crucial across the lifespan.  While much of the information on suicide prevention focuses on younger populations, older adults face distinct risks that may be overlooked in routine care. Loss of a spouse or social connections, chronic illness, pain, declining independence, and changes in cognitive or functional status create periods of increased vulnerability.  For physicians and care teams, recognizing these transitions, including the period around a new dementia diagnosis, creates an important opportunity to identify risk early, strengthen support, and proactively intervene.

Suicide Risk and Dementia: The Evidence Base

In 2023, Americans aged 85 and older had the highest overall age-specific suicide rate (22.7 deaths/100,000) (Centers for Disease Control and Prevention, 2025).  The gender difference is particularly striking.  Among men aged 75 and older, the 2023 suicide rate was 40.7 per 100,000, compared with 5.1 among women in that age group.

A large U.S. study of 2.67 million Medicare beneficiaries aged 65 and older and newly diagnosed with Alzheimer’s disease or related dementias found a suicide rate of 26.42 per 100,000 person-years during the first year after diagnosis. Overall suicide mortality was approximately 53% higher than expected, with the highest relative risk among people aged 65-74. In this study, risk was highest during the first 90 days following a dementia diagnosis. Rural residence and recent mental health, substance use, or chronic pain conditions were also associated with increased risk (Centers for Disease Control and Prevention, 2025).

Another population study (Schmutte, et al., 2021) found that dementia across the course of the disease was not associated with increased suicide risk, but risk was elevated during the first three months following diagnosis. Risk was further increased among people diagnosed before age 65 and those with a psychiatric comorbidity.

Suicide Prevention in Older Adults: Opportunities for Care Teams to Intervene

In addition to recognizing increased suicide risk in older adults, it is important to consider and integrate dementia diagnoses in this population.  The greatest concern is not necessarily advanced dementia.

Recognize a dementia diagnosis as a potential high-risk transition, not just a clinical event.

For clinicians, a new dementia diagnosis represents more than the beginning of a treatment and care plan. It also represents an important window for suicide screening and prevention. During this period, an individual has awareness and functional capacity and requires increased attention. 

Studies have found the highest suicide risk occurred within 90 days of a new dementia diagnosis, supporting suicide risk screening and support at the time of a new diagnosis, particularly among patients under age 75. In addition to screening, important conversations include how the patient is processing the diagnosis, losses the patient anticipates, available support, and changes family members noticed. 

Look for cumulative risk rather than a single risk factor.

Suicide risk increases with chronic illness, pain, mental health and substance use issues, isolation, functional loss, and unmet SDOH (social drivers of health). This creates a concept of cumulative vulnerability and the need to recognize when multiple changes are occurring in a patient’s life.

Make suicide prevention a care team responsibility.

Beyond screening, cumulative vulnerability creates a strong role for the care team: nursing, behavioral health, care management, social work, Community Health Workers (CHWs), and others. A CHW or care manager may learn that a patient has stopped social interactions, isn’t filling prescriptions, or is telling family members that they are becoming a burden. These observations need to be communicated back to the clinical team for action.

Suicide prevention in older adults requires recognizing periods of increased vulnerability, asking the right questions, connecting patients and families with support, and ensuring that concerns identified by any care team member reach a clinician. Together, these actions create a system of care in which early recognition, communication, and coordinated response make prevention possible before crises occur.

 

 

References

Centers for Disease Control and Prevention (2025). Garnett, M.F. & Zehner, A.M. Changes in suicide rates in the United States from 2022 to 2023. NCHS Datra Brief No. 541, September 2025.

 

Schmutte, T., Olfson, M., Maust, D.T., Xie, M., & Marcus, S.C. (2021). Suicide risk in the first year following dementia diagnosis in older adults. Alzheimers Dementia, 18(2), 262-271. Doi: 10.1002/alz12390.

 

Community Health Workers: Putting Return on Investment into Practice

 

In the first two parts of this series, we examined the expanding roles for Community Health Workers (CHWs) in primary care and multiple ways CHWs can contribute to financial performance.  We also challenged a common question: “How much can a CHW bill?”

This question focuses only on direct reimbursement and disregards much of the financial value CHWs can create. A more useful question for physician leaders is, “How can a CHW be deployed across our practice’s payer and patient mix to generate sufficient financial and clinical value to justify the investment?”

This answer to this question depends on practice size, payer mix, eligible patient populations, participation in care management programs, and strategic use of CHWs across multiple reimbursement and value-based opportunities.

The numbers demonstrate how this looks in practice.

Start with the Investment

Before calculating the return, practices need to understand the CHW investment.  For illustration purposes, assume that one full-time CHW ha a fully loaded annual cost of approximately $85,000 (including salary, benefits, payroll expenses, training, technology, supervision, and other employment-related expenses). 

An $85,000 annual investment amounts to approximately $7,083 in financial value per month to reach break-even.  The important point is that $7,083 should not come from one payer, one set of allowable billing codes, or entirely from direct reimbursement. 

Revenue We Can Measure  

Several existing revenue sources provide a starting point for calculating CHW financial contribution.

Medicare and Community Health Integration (CHI)  

Medicare Community Health Integration (CHI) is very relevant, because many CHI activities align closely with CHW roles, including patient-centered assessment, care coordination, health system navigation, facilitating access to community-based services, patient education and self-advocacy support, and communication with the healthcare team.

For 2026, the national Medicare non-facility payment for G0019 is approximately $86 for the first 60 minutes of CHI services during a calendar month.  Additional qualifying time may be billed using G0022.  Actual reimbursement varies geographically and according to applicable Medicare rquire4ments.

At approximately $86 per patient per month, the financial contribution becomes meaningful quickly.

Table 1. Active CHI Patients per Month Approximate Annual G0019 Revenue

Number of Patients	Approximate Annual Revenue based on $86 PMPM
25	$25,851
40	$41,362
50	$51,702
75	$77,553
83	$85,825

In this example, approximately 83 continuously eligible and billable CHI patients per month could generate annual G0019 revenue sufficient to cover the fully-loaded cost ($85,000) of one CHW.

This does not imply that every CHW should carry a panel of 83 CHI patients or that CHI alone should finance the position.  Relying on one reimbursement mechanism misses the larger CHW revenue opportunity.

Transitional Care Management (TCM)

Transitional Care Management (TCM) provides another source of CHW financial value. The CHW dose not independently bill TCM services.  However, the CHW can help the practice identify eligible patients following discharge, conduct outreach, address SDOH barriers (e.g., transportation), review an reinforce care plans, facilitate timely follow-up, and escalate clinical concerns to the appropriate care team member.

In 2026, national Medicare non-facility reimbursement is approximately $220 for CPT code 99495 and $299 for CPT 99496, depending on the complexity and requirements of the transition.

If CHW-supported workflows help a practice achieve eight additional TCM episodes per month (using a blended reimbursement of $240 as an example), the practice could capture approximately $23,000 in additional annual TCM revenue.  

Again, this revenue is NOT billed independently by the CHW and depends on the structure and processes of workflows incorporating CHWs, where appropriate. .

Michigan Medicaid

Michigan Medicaid provides direct reimbursement for qualifying CHW services, creating a strong potential revenue stream for practices serving Medicaid beneficiaries.

This is especially important when building the business case for CHWs. Practices do not need to rely solely on Medicare CHI reimbursement to support CHW investment; CHW capacity can be aligned across Medicare, Medicaid, and commercial care management populations.

Medicaid CHW reimbursement may contribute significantly to the cost of a CHW position.

Provider Delivered Care Management (PDCM)

For practices participating in Blue Cross Blue Shield of Michigan’s Provider Delivered Care Management (PDCM) program, CHWs may also contribute to reimbursable are management activities within program requirements.

CHWs support patient outreach, care coordination, chronic disease management, transitions of care, self-management, and patient engagement. PDCM is another source of financial return, particularly for practices with well-established care management infrastructure.

PDCM is best calculated based on individual payer agreement, patient enrollment, and patient risk mix. 

Potential CHW Return on Investment for a Small Practice

As an example, we will define a small practice as one with four or fewer physicians employing one fully-loaded CHW at an annual cost of $85,000.

Table 2. Potential CHW Revenue in a Small, Multi-payer Practice with one CHW

Financial Contribution	Example Annual Value
40 active Medicare CHI patients/month	$41,362
8 additional completed TCM episodes/month	$23,040
Michigan Medicaid CHW services	$10,000
Subtotal measurable financial contribution	$74,402
Amount to reach break-even	$10,598

This practice would need approximately $883 per month in additional revenue to reach the $85,000 break-even point.  This may be from PDCM, additional CHI services, additional Medicaid CHW services, other commercial care management programs, or other payer-specific reimbursement opportunities.  This calculation has not assigned financial value to Medicare Advantage quality performance, shared savings, reduced ED utilization, reduced hospital admissions, improved patient engagement, or increased staff capacity resulting from integrating CHWs in workflows. 

Practice Size, Payer Mix, and Patient Opportunities

The potential return on investment for CHW integration varies with practice size, payer mix, and patient opportunities.  This is illustrated in the following example.

Table 3. Illustrative ROI by Practice Size and Programs

Financial Contribution/Revenue	Small Practice	Medium Practice	Large Practice
Active CHI patients/month	40	50	75
Approximate annual CHI revenue	$41,362	$51,702	$77,553
Additional TCM episodes/month	8	12	16
Approximate Annual TCM revenue	$23,040	$34,560	$46,080
Illustrative Medicaid/PDCM/other	$21,000	$25,000	$35,000
TOTAL MEASURABLE FINANCIAL CONTRIBUTION	$85,402	$111,262	$158,633
Illustrative CHW cost	$85,000	$85,000	$85,000
Net Measurable Contribution	+$401	`+$26,262	`+$73,633
Illustrative ROI	~0.5%	~31%	$87%

These examples illustrate how aligning CHWs with payer mix and eligible patient/program populations change the financial potential. A small practice may reach break-even with one CHW, while a medium or large practice may have greater opportunity to add CHW capacity and reimbursement.

Small practices may also elect to share a CHW as they build program capacity.   

These examples do not include all activities where CHWs may contribute to revenue, such as Medicare Advantage Stars, quality incentives, shared savings, reduced unnecessary ED utilization, and improved patient experience.

Summarizing the Business Case

The question is whether one or more CHWs can generate break-even revenue to provide a practice with financial value.  The strongest CHW business model is built by deliberately and strategically deploying CHW capacity across populations, payer programs, and organizational priorities to create sufficient combined value.  This creates the combined financial and clinical value of adding CHWs as essential members of the care team.   

 

NOTE: Financial examples are presented as illustrations and are not guarantees of financial performance or return. Practices should verify current payer policies, contracts, and fee schedules when developing financial projections.

 

 

August 24-28, 2026 – Celebrating Community Health Workers

Community Health Worker Week is a time to recognize, celebrate, and thank the Community Health Workers (CHWs) who make a difference in the lives of individuals, families, and communities every day.

CHWs are trusted members of the communities they serve. They listen, build relationships, connect people to resources, help individuals navigate health and social service systems, and often serve as the bridge between a person and the care they need.

CHWs meet people where they are and help them take the next step. Whether it is helping someone find access to food, transportation, housing, health care, or other community resources. A Community Health Worker supports and meets individuals as they work toward healthier choices and better management of a chronic condition.

Celebrating the Impact of CHWs

CHWs bring lived experience, cultural understanding, local knowledge, and trusted relationships to the teams they are a part of. They help organizations better understand the needs of the communities they serve while helping individuals feel heard, supported, and connected.

Health care providers and community-based organizations that incorporate CHWs into the team can strengthen the connection between clinical care and the everyday circumstances that influence a person's health.

Is Your Organization Ready to Invest in CHWs?

If your organization is considering hiring a CHW or interested in training a current staff member to become a CHW, education is an important place to start.

PTI's Community Health Worker Program provides comprehensive training aligned with the National C3 Council's core competencies. The curriculum addresses essential topics including, communication, motivational interviewing, brief action planning, social drivers of health, community resources and navigation, chronic conditions, healthy lifestyles and disease prevention… and MUCH more!

PTI is an approved entity by the Michigan Department of Health and Human Services (MDHHS) to provide CHW training for individuals seeking CHW certification. PTI is also accredited by the International Accreditors for Continuing Education and Training (IACET), allowing participants to earn IACET CEUs for eligible educational activities. 

Interested in Becoming a CHW?

If you are passionate about helping others, connecting people with resources, advocating for individuals and families, and making a difference in your community, a career as a CHW may be an opportunity to turn that passion into meaningful work.

PTI's upcoming Community Health Worker Program provides an opportunity for individuals to develop the skills and knowledge needed to serve effectively as a CHW.

Learn more about the upcoming training and registration opportunities:
https://web.cvent.com/event/b9deda35-7171-4f28-8449-9977442d9fb3/summary

Whether you are an experienced CHW, an organization looking to strengthen your CHW workforce, or someone considering becoming a CHW, there is an opportunity to learn, grow and make an impact.

Thank you to the Community Health Workers who show up, listen, connect, advocate, and help their communities move forward. We will be highlighting a few PTI trained CHW's this week. 

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