The Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model on July 1, 2024. Running from 2024 through 2032, this program is one of the first Innovation Center care models to focus on longitudinal, condition-specific comprehensive care.
As a voluntary nationwide model test with nearly 400 nationwide participants, GUIDE aims to support hundreds of thousands of Medicare beneficiaries living with dementia and their unpaid caregivers.
The program provides Medicare payments to provider organizations and their partners through:
- A comprehensive package of care coordination and care management
- Caregiver education and support
- Respite services
GUIDE supports patients with dementia and caregivers
Dementia affects more than 6.7 million Americans today and is expected to more than double by 2060. Patients with dementia tend to have multiple chronic conditions and experience fragmented care, which can lead to high rates of hospitalization and emergency department visits. Many also need 24-hour care and face high rates of depression with behavioral and psychological symptoms.
The informal caregivers who provide constant support face their own struggles with the mental, physical, emotional, and financial burden. About 30% of dementia caregivers are Medicare beneficiaries themselves.
These challenges disproportionately affect Black, Hispanic, Asian, Native Hawaiian, and Pacific Islander caregivers.
The GUIDE model aims to provide ongoing funding for a standardized approach to care. The goal is to enable patients with dementia to remain safely in their homes, preventing or delaying nursing home placement while improving the patients' and caregivers' quality of life.
Focusing on reducing disparities and incorporating policies to enhance health equity, GUIDE aims to help underserved communities have equal access to interventions.
Which providers and patients may participate in the GUIDE program?
There are two tracks for participating provider organizations. The Established Program Track launched in July 2024 with 96 organizations. This track is for participants who are already providing comprehensive dementia care and are able to immediately fulfill GUIDE’s care delivery requirements.
CMS assigned the remaining 294 participants to the New Program Track. The New Program Track is intended for participants who need more time to develop their Dementia Care Programs (DCPs), and will launch GUIDE services on July 1, 2025. A participant list can be found here.
GUIDE providers
Organizational participants include Medicare Part B-enrolled providers and suppliers. They’ve demonstrated experience and capacity to provide ongoing, longitudinal care to people with dementia through an interdisciplinary team.
Per GUIDE’s Interdisciplinary Care Team requirements, participant care teams must include, at a minimum, a care navigator and a clinician with “dementia proficiency,” who is eligible to bill Medicare Part B evaluation and management services (E/M). Dementia proficiency is defined as meeting one of the following criteria:
- Minimum of 25% of a clinician’s patient panel comprises adults with any cognitive impairment, including dementia
- Minimum of 25% of a clinician’s patient panel is 65 years old or older
- Specialty designation of neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology
Those unable to meet the GUIDE care delivery requirements are authorized to contract with other Medicare providers and suppliers. These “partner organizations” include respite providers, adult daycare centers, hospitals, community-based organizations, home health agencies, and others.
Figure 1 outlines practitioner and partner requirements. Source.
Figure 2 highlights the types of participant service area communities. About 32% of DCPs operate or will operate in rural or urban areas supporting low socio-economic communities. Source.
Among all participants, 68% are from physician group practices or clinics.
Eligible GUIDE beneficiaries
Medicare and dually eligible beneficiaries who have an attested dementia diagnosis by a participating clinician are eligible if they meet additional criteria, including:
- Living at home or in a community-dwelling
- Enrolled in Medicare Parts A & B or dually eligible for Medicare and Medicaid
- Not enrolled in Medicare Advantage or Special Needs Plans (SNPs)
- Not residing in a long-term nursing home
- Not receiving hospice services
- Not receiving PACE services
Dementia program elements and requirements
The GUIDE Model sets a standard approach to comprehensive, coordinated dementia care. Providers must offer nine clinical and non-clinical service components, either directly or through a partner organization.
GUIDE service components
- Comprehensive assessment using approved screening tools, including The Clinical Dementia Rating (CDR) and the Functional Assessment Staging Test (FAST). These help clinicians stage dementia and evaluate caregiver burden. Additionally, screening for health-related social needs and an in-home evaluation identify psychosocial and safety needs.
- Care plans are created by care managers to address patient and caregiver goals, preferences, and needs.
- 24/7 access to a care team member via a helpline or third-party vendor during off-duty hours.
- Ongoing monitoring and support to update care plans, assess progress on goals and determine if new needs have arisen.
- Community-based referrals and coordination for services like home-delivered meals and transportation.
- Care coordination and specialist support enable timely referrals to specialists to address comorbidities or other chronic conditions.
- Respite services are provided if the beneficiary has an unpaid caregiver, enabling temporary breaks from caregiving responsibilities via an adult day center or facility with 24-hour care.
- Medication management is conducted periodically to reconcile medications and avoid interactions or polypharmacy.
- Caregiver education and support may include training programs on best practices for caring for a loved one with dementia and managing their own health despite caregiving duties.
How will CMS pay providers for the GUIDE program?
CMS provides an alternative payment methodology that includes a monthly per-beneficiary payment to support a team-based collaborative care approach.
As shown in Figure 3, several elements affect the bundled payment rate, including:
- Monthly dementia care management payment (DCMP)
- Length of time in program (first 6 months/after 6 months)
- Complexity
- Geography
- Performance-based adjustment
- Health equity adjustment (HEA)
- Caregiver involved
- Respite care
Figure 3 shows what determines the GUIDE program bundled payment. Source.
Eventually, CMS looks to include a five-measure set, including:
- One clinical quality process measure
- Two patient-reported outcome measures
- One cost measure
- One utilization measure
Figure 4 outlines the payment rates based on a patient’s complexity level, whether they have a caregiver, and whether the patient is new or established in the program. Source.
One-time payment for safety-net providers
Participants classified as safety-net providers may also be eligible for a one-time infrastructure payment of up to $75,000.
These funds can be used for:
- Hiring
- Training
- Developing program workflows, protocols, materials, and partnerships
- Community outreach and engagement
- Software or adaptations to manage the program
Allowable concurrent CMS programs
CMS allows GUIDE organizations to participate in other Innovation Center Models, including the Medicare Shared Savings Program (MSSP). The following programs can be implemented concurrently with GUIDE:
- Shared savings programs and ACO models like ACO Reach and Kidney Care Choices
- Advanced and Comprehensive Care for Joint Replacement (CJR) models
- Innovation Center models with care management payment, including: Primary Care First, Making Care Primary and Enhancing Oncology Care
When GUIDE is added to these complementary programs, it enhances services for beneficiaries with dementia and their caregivers, as well as enhances financial reimbursement for providers.
ThoroughCare aligns with GUIDE program elements
ThoroughCare is built upon evidence-based workflows and standards that match CMS requirements for care management programs, such as Chronic Care Management, Transitional Care Management, and Remote Patient Monitoring.
Many GUIDE requirements can be satisfied through ThoroughCare, including:
- Health-related social needs assessment
- Personalized care plan development and oversight
- Medication adherence
- Care coordination and referral management
- Community resources
- Caregiver communication and coordination
ThoroughCare delivers integrated care management services to foster patient engagement and enhance revenue. Our platform provides the digital infrastructure to leverage CMS payment for standardized programs that rely on care coordination, performance measurement, and monthly billing.
Key questions answered
What is CMS's GUIDE Model — Guiding an Improved Dementia Experience?
GUIDE is an eight-year Innovation Center care model focused on longitudinal, standardized care for Medicare beneficiaries with dementia and their unpaid caregivers. The program provides Medicare payments to provider organizations and their partners through a comprehensive package of care coordination and care management, caregiver education and support, and respite services.
How will the GUIDE program support patients with dementia, as well as caregivers?
GUIDE supports a per beneficiary per month payment and potential one-time infrastructure payment for safety-net providers. GUIDE reimburses for services, including assessments, care planning, coordination, and referrals with specialists and community resources, as well as caregiver training and temporary respite.
The GUIDE Model sets a standard approach to comprehensive, coordinated dementia care. Providers must offer nine clinical and non-clinical service components, either directly or through a partner organization.
Additionally, GUIDE encourages improving dementia care for historically underserved populations experiencing inequity by weighting payments for providers.