June is Alzheimer’s & Brain
Awareness Month which spotlights dementia as one of the most urgent public
health issues in the United States.
Primary care is central to dementia screening, identification, ongoing
management, and caregiver support.
Alzheimer’s disease is a progressive
neurodegenerative disorder that primarily affects memory, thinking, and
behavior, eventually interfering with daily life and the ability to perform
basic tasks such as eating or walking (National Institute on Aging, 2025). Alzheimer’s disease is the most common form
of dementia affecting an estimated 7.4 million Americans (Alzheimer’s
Association, 2026). Alzheimer’s disease
and other dementias place significant emotional, clinical, and financial strain
on families and healthcare systems. Adding to the problem, many patients remain
undiagnosed until symptoms become severe. Alzheimer’s begins 20 years or more
before memory loss and other symptoms develop, providing an increased window
for early diagnosis and support (Alzheimer’s Association (2026). The following table represents the distribution
of Alzheimer’s by age group in the United States.
Dementia is a Primary Care Issue
The US
population is aging and increasing numbers of patients present in primary care
settings with memory and behavioral changes and cognitive decline. At the same time, increasing administrative
demands, workforce shortages, and fragmented systems make it difficult for
physicians to deliver dementia care within existing appointment
structures.
Primary care
providers often develop long-term relationships with patients and families and
are positioned to identify early cognitive changes. These changes often
manifest as missed appointments, difficulty with medication management,
confusion or changes in ability to retain information during visits, family
concerns about cognition, and increases in Emergency Department (ED) use.
However, due
to dementia complexity and progression, management extends far beyond clinical
diagnosis. Patients with dementia face
significant barriers with transportation, health literacy, communication,
social interaction, and stigma.
Community
Health Workers Support Team-based Dementia Care
Patients
with dementia often need assistance with social determinants of health (SDOH)
such as transportation, home safety, and nutrition. Other areas of frequent need include
medication adherence, insurance and benefits, caregiver respite, and behavior
symptom management. These complex needs
are difficult to address during brief office visits.
Community
Health Workers (CHWs) play a fundamental role in dementia management. CHWs provide patient and caregiver support
through regular check-ins, emotional support, education, and referrals to
community services and resources for support groups or respite. For patients
with dementia and co-existing chronic conditions (such as diabetes,
hypertension, heart disease, and depression) CHWs can reinforce self-management
strategies, identify barriers, and huddle with the healthcare team to bridge
the gap between medical care and community needs.
CHWs are
also able to support patients and caregivers between clinical visits by
conducting outreach and follow-up; reinforcing care/action plans; providing
culturally responsive, health-literacy-sensitive education; connecting families
to local services; supporting medication understanding; helping caregivers
navigate complex health systems; and identifying programs and services to
reduce caregiver burnout. This level of
CHW support can significantly improve quality of life and continuity of care
for patients with dementia and their caregivers.
Research has
shown that community-based interventions may reduce avoidable Emergency
Department (ED) visits and hospital admissions among older adults with complex
health needs. In addition to cost and decreased fragmentation of care, an
important aspect of ED and hospital admission avoidance is understanding the
disruption and stress caused by change in routines for dementia patients. By
reducing unnecessary utilization, CHWs also contribute to improved quality of
care and patient/family experience.
Integrating
CHWs into Primary Care Using Existing Infrastructure
Primary care
practices do not necessarily need to build dementia support services from the
ground up. Community-based
organizations, payers, health systems, and others increasingly use CHWs in care
management, population health, and other are management programs. Strategies applicable to dementia care
include assigning or embedding CHWs in specific primary care practices,
creating referral pathways for dementia support service, training CHWs in
dementia education at the community and patient/caregiver levels, and using
available coding/billing mechanisms (particularly with Medicare and
Medicaid).
Primary care
physicians and providers play a crucial and expanding role in dementia care,
including strong community-based interventions, continued attention to SDOH,
and collaborative care models. CHWs are
positioned to support effective dementia care in primary care settings.
Practice
Transformation Institute CHW Training Programs
The
Practice Transformation Institute (PTI) CHW educational programs are designed
to strengthen CHW knowledge, performance, and impact. PTI is an approved
provider of Community Health Worker training by the Michigan Department of
Health & Human Services (MDHHS), following a rigorous approval process and
years of community and health system partnership. PTI is also uniquely
distinguished by its IACET accreditation, underscoring its commitment to
training excellence.
PTI’s
CHW program teaches the nationally recognized C3 Council competencies and
equips participants with the skills needed to function effectively across a
variety of community and health care settings. This robust training supports
CHWs in contributing meaningfully to cost reduction, improved outcomes, and
sustainable system transformation.
Learn More: https://transformcoach.org/learning-solutions/community-health-worker-chw-program/
Register: https://web.cvent.com/event/b9deda35-7171-4f28-8449-9977442d9fb3/summary
References
Alzheimer’s
Association (2026). Special report:
Brain health in America: Understanding and supporting lifelong cognitive
health. https://www.alz.org/getmedia/ef8f48f9-ad36-48ea-87f9-b74034635c1e/alzheimers-facts-and-figures.pdf
Centers for
Disease Control and Prevention (2024).
About Alzheimer’s. About Alzheimer's | Alzheimer's Disease and Dementia | CDC
National
Institute on Aging, National Institute for Health (2025). What is Alzheimer’s Disease? What Is Alzheimer's Disease? | National Institute on Aging
