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:
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.
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.
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:
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.
Medicare and dually eligible beneficiaries who have an attested dementia diagnosis by a participating clinician are eligible if they meet additional criteria, including:
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.
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:
Figure 3 shows what determines the GUIDE program bundled payment. Source.
Eventually, CMS looks to include a five-measure set, including:
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.
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:
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:
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 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:
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.
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.
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.