On July 1, 2024, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improved Dementia Experience (GUIDE) Model, a significant step forward in dementia care. Following this launch, on July 8, 2024, CMS announced the 390 healthcare organizations participating in this innovative program. For those seeking detailed information, CMS has provided a comprehensive blog post and a downloadable list of participating organizations.
The GUIDE Model is a voluntary, nationwide initiative designed to provide crucial support for individuals living with dementia and their dedicated unpaid caregivers. Launched on July 1, 2024, this model is set to operate for eight years, aiming to transform the landscape of dementia care.
Understanding the GUIDE Model: A Medicare Initiative for Dementia Care
The core objective of the GUIDE Model is to deliver comprehensive and coordinated dementia care, ultimately enhancing the quality of life for people with dementia. It also focuses on alleviating the considerable strain experienced by their unpaid caregivers and empowering individuals with dementia to remain in the comfort and familiarity of their own homes and communities for as long as possible. To achieve these ambitious goals, Medicare will facilitate payments for a holistic package encompassing care coordination, comprehensive care management, essential caregiver education and support, and much-needed respite services.
This model directly responds to the Biden Administration’s Executive Order 14095 from April 2023, which emphasizes increasing access to high-quality care and robust support for caregivers. The Executive Order specifically instructed the Department of Health and Human Services to explore innovative payment and service delivery models within Medicare and Medicaid that prioritize dementia care, including respite care and other vital family caregiver supports.
Furthermore, the GUIDE Model is a crucial element in advancing the objectives of the National Plan to Address Alzheimer’s Disease. This plan, born from the bipartisan National Alzheimer’s Project Act (NAPA), has been instrumental for over a decade in driving federal initiatives to improve dementia care quality and accelerate research towards effective treatments and a cure. The GUIDE Model builds upon this extensive inter-agency coordination and incorporates valuable input from numerous external stakeholders and experts in the field.
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| – Dementia prevalence is a growing concern, affecting over 6.7 million Americans in 2023, with projections reaching 14 million cases by 2060. – Individuals with dementia often face complex health challenges, managing multiple chronic conditions and experiencing fragmented care pathways. This frequently leads to higher rates of hospitalizations and emergency department visits. Behavioral health symptoms and the need for round-the-clock care are also common, placing immense mental, physical, emotional, and financial burdens on caregivers. These burdens disproportionately affect underserved communities, including Black, Hispanic, Asian Americans, Native Hawaiian, and Pacific Islander populations. – The GUIDE Model establishes a standardized approach to dementia care, ensuring essential elements such as 24/7 access to a support line and comprehensive caregiver training, education, and support services. This standardized care framework aims to enable people with dementia to live safely at home for longer, delaying or preventing nursing home placement, and significantly improving the quality of life for both individuals with dementia and their unpaid caregivers. – To promote equitable access to dementia care, the GUIDE Model actively integrates policies designed to enhance health equity, ensuring that underserved communities benefit equally from the model’s interventions and resources. |
The Purpose Behind the Medicare GUIDE Model
Despite the widespread impact of dementia, many individuals do not consistently receive the high-quality, coordinated care they urgently need. This gap in care often results in adverse outcomes, including increased hospitalizations, frequent emergency department visits, and greater utilization of post-acute care services. People with dementia also experience higher rates of depression, challenging behavioral and psychological symptoms, and suboptimal management of co-occurring health conditions.
The impact of dementia extends significantly to family members and other unpaid caregivers. These individuals often provide extensive support with personal care, financial management, household tasks, medication management, clinical coordination, and a wide range of other caregiving responsibilities. Alarmingly, many caregivers of people with dementia, who are often Medicare beneficiaries themselves, report high levels of stress and depression. This not only diminishes their own well-being but also increases their risk of serious illness, hospitalization, and even mortality.
Through the GUIDE Model, CMS is actively testing an innovative alternative payment structure for participating organizations that are committed to delivering comprehensive, coordinated dementia care. Under this model, participants will assign each person with dementia and their caregiver to a dedicated Care Navigator. This navigator will serve as a central point of contact, helping them access the services and supports offered within the GUIDE Model, as well as connecting them with essential non-GUIDE services. These may include clinical services and vital non-clinical services, such as meal delivery and transportation assistance, often available through community-based organizations.
A key focus of the GUIDE Model is to significantly enhance access to the support and resources that caregivers desperately need. Unpaid caregivers will be connected to evidence-based education and support programs, including specialized training on best practices for caring for a loved one with dementia. Model participants will also facilitate caregiver access to respite services. Respite care provides temporary breaks from caregiving responsibilities, allowing caregivers to rest, recharge, and attend to their own needs.
Extensive research demonstrates that consistent use of respite services empowers unpaid caregivers to continue providing care at home for longer periods. This can effectively prevent or delay the need for institutional facility care. Furthermore, the GUIDE model is strategically designed to reduce overall Medicare and Medicaid expenditures. This is primarily achieved by enabling people with dementia to remain in their homes, thereby reducing hospitalizations, emergency department use, the need for costly post-acute care, and long-term nursing home care.
Image alt text: Infographic contrasting the fragmented current dementia care pathway with the improved coordinated pathway offered by the GUIDE Model, highlighting enhanced support and better outcomes.
Key Elements of the GUIDE Model Design
Organizations participating in the GUIDE Model are Medicare Part B enrolled providers and suppliers. They are tasked with establishing comprehensive Dementia Care Programs (DCPs) that deliver ongoing, longitudinal care and support to individuals with dementia through a dedicated interdisciplinary team of healthcare professionals.
Recognizing that some participants may require additional support, the GUIDE Model allows participants to partner with other Medicare providers and suppliers (“Partner Organizations”) to collectively meet the comprehensive care delivery requirements.
The eight-year model is structured into two distinct tracks: one for established dementia care programs and another for new programs. Established programs, those with prior experience serving the dementia population and already delivering most of the GUIDE care delivery requirements, commenced providing GUIDE services on July 1, 2024. New programs, on the other hand, are provided with a one-year pre-implementation period, starting July 1, 2024, and concluding on June 30, 2025. This period allows them to effectively establish their programs before beginning to deliver GUIDE services on July 1, 2025. CMS is committed to supporting all participating organizations through technical assistance, learning collaboratives, and the pre-implementation year for new programs, ensuring they are well-prepared for successful model participation.
The GUIDE Model strategically addresses the primary factors contributing to suboptimal dementia care quality through five key approaches:
- Standardizing Dementia Care Delivery: The model defines a clear, standardized approach to dementia care delivery for all participants. This includes specific guidelines for staffing, essential services for people with dementia and their unpaid caregivers, and rigorous quality standards to ensure consistent, high-quality care.
- Alternative Payment Methodology: CMS implements an alternative payment methodology, providing participating organizations with a predictable monthly per-beneficiary payment. This payment is designed to support a team-based, collaborative care approach, fostering better coordination and comprehensive service delivery.
- Addressing Unpaid Caregiver Needs: Recognizing the immense burden on unpaid caregivers, the model mandates that participants provide comprehensive caregiver training and support services. This includes 24/7 access to a dedicated support line, ensuring caregivers can access assistance whenever needed, and facilitated connections to community-based providers offering additional resources and support.
- Respite Services Integration: CMS directly funds respite services within the GUIDE Model. These vital services offer temporary care for beneficiaries, provided in their homes, at adult day centers, or in facilities offering 24-hour care. The explicit purpose is to provide unpaid caregivers with essential temporary breaks from their demanding caregiving responsibilities, promoting their well-being and sustainability in their caregiving role.
- Screening for Health-Related Social Needs: Model participants are required to proactively screen beneficiaries for psychosocial needs and health-related social needs (HRSNs). Furthermore, they are responsible for actively navigating beneficiaries to local, community-based organizations that can effectively address these identified needs, recognizing the crucial link between social determinants of health and overall well-being.
Advancing Health Equity in Dementia Care
A central tenet of the GUIDE Model is the commitment to delivering equitable care and actively addressing health disparities within dementia care.
Dementia-related challenges, including financial strain, emotional stress, and logistical complexities, are often disproportionately amplified for specific racial and ethnic groups. Data reveals that Black and Hispanic populations experience a higher prevalence of dementia. Simultaneously, they are less likely to receive timely diagnoses, face more unmet needs, experience greater caregiving demands, and allocate a larger proportion of their family assets to cover dementia care costs.
CMS proactively sought out eligible organizations that serve underserved communities to actively participate in the GUIDE Model. Recognizing the unique challenges faced by safety-net providers, the GUIDE Model offers a range of financial and technical supports. These supports are specifically designed to enable these organizations to develop robust infrastructure, enhance their care delivery capabilities, and successfully participate in the model, ensuring equitable access to high-quality dementia care for vulnerable populations.
The GUIDE Model also prioritizes individuals with dementia who are dually eligible for both Medicare and Medicaid. Consistent with the model’s overarching goals, the aim is to provide these individuals with the comprehensive support needed to remain safely in their homes and communities for as long as possible, improving their overall well-being and reducing reliance on institutional care.
Specific aspects of the GUIDE Model designed to tangibly improve health equity include:
- Mandatory HRSN Screenings and Referrals: Requiring all participating providers to implement consistent Health-Related Social Needs (HRSN) screenings and establish clear referral pathways to address identified needs.
- Targeted Support for Underserved Areas: Offering dedicated financial and technical support for the development of new dementia care programs specifically targeted towards underserved areas that currently lack adequate access to specialized dementia care services.
- Annual Health Equity Reporting: Requiring participating organizations to submit annual reports detailing their progress towards achieving defined health equity objectives, outlining their strategies, and tracking their progress against specific targets.
- Data-Driven Disparity Identification and Improvement: Leveraging data collected through the model to systematically identify existing disparities in dementia care access and outcomes. This data-driven approach will inform targeted quality improvement activities and resource allocation to address identified inequities.
- Health Equity Payment Adjustment: Incorporating a health equity adjustment to the model’s monthly care management payment. This adjustment provides additional financial resources to support the care of underserved beneficiaries, recognizing the increased complexity and resource needs often associated with these populations.
Stay Informed about the GUIDE Model
For those interested in staying up-to-date on the GUIDE Model, or for organizations seeking to participate in future initiatives, CMS provides several resources. Further details regarding past events, model background, technical resources, and outreach information can be found on the dedicated CMS GUIDE Model webpages. By focusing on comprehensive, coordinated care and actively addressing health equity, the Medicare Guide Model represents a significant stride towards a better future for individuals living with dementia and their caregivers.
