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. 

🌟Follow Along! 🌟

Community Health Workers: Understanding the Return on Investment

 

Introduction

Last month, we discussed how Community Health Workers (CHWs) create value across multiple payers, including Medicare, Medicaid, and commercial insurance and through programs such as Provider Delivered Care Management (PDCM), Transitional Care Management (TCM), and other value-based initiatives. A question frequently asked by physician leaders is, “Can a CHW generate enough financial return to justify the investment?”  Increasingly, the answer is yes, but not for the reasons many practices expect. 

The Wrong Question

Many practices or organizations begin by asking, “How much can a CHW bill?”  This is an understandable question, but it is the wrong place to start. 

As discussed last month, the financial value of a CHW should not be measured by a limited number of billing codes.  Instead, physician leaders should evaluate CHWs based on their contribution to direct reimbursement, care management, quality performance, operational efficiency, and value-based payment opportunities.   

Table: Examples of Community Health Worker Financial Opportunities

This table demonstrates that the financial value of a CHW extends well beyond direct reimbursement. It is recommended to check with the payer to determine payment policies and approval rules.  A single patient interaction may simultaneously support billable services, quality performance, care management objectives, care coordination, education, reduced avoidable utilization, and improved patient experience.  Viewed together, these contributions create a cumulative financial impact that often exceeds the value of any individual billing code.  

For physician leaders, the important question is how to maximize the financial and clinical value created by CHWs across multiple payer programs.  

Michigan’s Leadership in Team-Based Care

Michigan has long been a leader in developing and implementing innovative models that support coordinated, team-based care. Programs such as Patient-Centered Medical Homes (PCMH), BCBSM Provider-Delivered Care Management (PDCM), and value-based payment initiatives have established a strong foundation for integrating CHWs into primary care.

Emerging direct reimbursement opportunities and value-based payment models now provide the financial foundation to support that integration, enabling physician practice to align improved patient outcomes, with sustainable practice performance. 

Community Health Workers: A Revenue Opportunity for Primary Care Physicians

 

Community Health Workers (CHWs) are often thought of as staff allocated for short-term initiatives, grants, or public health programs.  Changes in Medicaid, Medicare, and commercial payer reimbursement have created new opportunities for physicians, especially for those in primary care, to integrate CHWs into care teams, generating sustainable revenue, improving quality metrics, and reducing care team burden.  The question is no longer whether practices can afford to employ CHWs but whether they can afford not to.   

This month (part one of a two-part series), we begin by exploring CHW roles and revenue opportunities across payers. 

Next month, we will take a closer look at how CHWs can provide a positive return on investment and discuss specific opportunities involving direct reimbursement, Transitional Care Management (TCM), Medicare Community Health Integration (CHI), Provider Delivered Care Management (PDCM), and value-based reimbursement models. 

CHWs and Michigan’s Leadership in Team-Based Care

Original Medicare, Medicaid, and commercial payers recognize CHWs as bringing value to patient care, care coordination, and population health.  As reimbursement opportunities expand, CHWs have become important members of the healthcare team, bringing revenue and value to physician practices.   

Michigan has long been recognized for its commitment to team-based care and innovative payment models that support care coordination.  Through initiatives involving Original Medicare, Medicaid, commercial payers, and physician organizations, Michigan has actively demonstrated the value of multidisciplinary care teams to improve patient outcomes, reduce avoidable healthcare utilization, and reduce cost. 

Programs such as BCBSM-developed Provider Delivered Care Management (PDCM), patient-centered medical homes (PCMH), population health initiatives, and Medicaid Community Health Worker reimbursement have created opportunities for practices to expand care teams and address factors influencing health outside the clinic setting.

CHWs are a logical and natural extension of these efforts.  Their ability to support patients during transitions of care (e.g., emergency department (ED) visits, hospital discharges, and movement between healthcare settings) aligns with the goals of improving care coordination and strengthening patient engagement.

As healthcare continues moving to value-based care, Michigan practices are strongly positioned to include CHWs in broad strategies to improve outcomes, enhance patient experience, and support financial performance across multi-payer programs.

Transitions of Care and the CHW: More than Community Outreach 

One of the most valuable roles for CHWs is supporting transitions of care.   

Patients are particularly vulnerable when moving between health care settings, such as:  

• ED to home  
• Hospital to home
• Hospital to Skilled Nursing Facility or Rehabilitation 
• Skilled nursing facility or rehabilitation to home

These transitions are often overwhelming for patients and families/caregivers who may struggle to understand discharge instructions, comprehend medications, schedule follow-up appointments, arrange transportation, and access community resources.  These challenges often result in lack of primary care follow-up, return to ED, or possible avoidable readmission. 

CHWs support patients and families during transitions by: 

• Following up after ED visits or hospitalizations
• Reinforcing discharge instructions
• Assisting with medication access and adherence (within scope)
• Scheduling primary care and other follow-up appointments
• Identifying barriers that could lead to returns to ED or inpatient readmissions
• Observing and escalating patient needs to the care team 

By helping patients successfully transition between care settings, CHWs support continuity of care, improve patient self-management, and reduce avoidable utilization.

Reimbursement Opportunities Across Payers

When incorporated into the care team, CHW services provide sustainable revenue for primary care practices. Recognizing that this revenue stream extends beyond a single payer is crucial.  

Medicare

Original Medicare now reimburses Community Health Integration (CHI) services that address care coordination, social needs, patient navigation, and other activities that fall within CHW scope and help patients successfully engage in care.

Medicaid

State Medicaid programs, including Michigan Medicaid, now reimburse for CHW services.  This creates opportunities for practices serving Medicaid beneficiaries to integrate CHWs into care teams while supporting improved patient outcomes.

Commercial Insurance

Commercial payers increasingly support team-based care, care management, and value-based payment arrangements that align with CHW services.  Many physician organizations participate in programs that reward improved outcomes, care coordination, and avoidable utilization.

CHW Reimbursement: A Layered Approach

One of the most common misconceptions about CHWs is that their value should be measured using a single reimbursement mechanism.  CHWs contribute to direct reimbursement, quality performance, care management initiatives, utilization reduction, patient engagement, and multi-payer value-based payment programs.  The greatest return combines multiple payer programs and financial incentives. When making the decision to employ CHWs, the meaningful question to consider is how many organizational goals can CHWs help achieve? 

For example, a CHW supporting patients after ED visits may contribute to the following:

• Original Medicare Community Health Integration (CHI) services
• Medicaid CHW reimbursement
• Transitional Care Management (TCM) services
• BCBSM-developed Provider-Delivered Care Management (PDCM) goals
• Medicare Advantage quality measures
• Reduced hospital readmissions
• Reduced ED utilization
• Improved patient engagement and experience

Value-based care has become a realistic goal. CHWs are essential to create value across all payers. 

The true value of a CHW is not tied to one patient, payer, or billing code.  More often, it is found in the combined impact they create across the healthcare system. 

Next month, in part two, we will examine specific codes, direct reimbursement, and begin to understand return on CHW investment.