According to CMS, “about 6.7 million Americans currently live with  Alzheimer’s Disease or another form of dementia, a number that is projected to grow by nearly 14 million by 2060.”  To help combat the rising cry for help from unpaid caregivers and address the unique needs of this population, CMS has developed an innovative test model as a new approach to how Medicare will pay for the care of people living with dementia: the Guiding an Improved Dementia Experience Model, or GUIDE Model. 

The GUIDE Model has three specific goals: “1. to improve quality of life for people living with dementia by addressing their behavioral health and functional needs, coordinating their care for dementia and co-occurring conditions, and improving transitions between community, hospital and post-acute settings; 2. to reduce burden and strain on unpaid caregivers of people living with dementia by providing caregiver skills training, referrals to community-based social services and supports, 24/7 access to a support line, and respite services; and 3. to prevent or delay long-term nursing home care for as long as appropriate by supporting caregivers and enabling people living with dementia to remain safely in their homes for as long as possible.”

The GUIDE Model will test a new payment approach for key supportive services furnished to people living with dementia, including: comprehensive, person-centered assessments and care plans; care coordination; 24/7 access to an interdisciplinary care team member or help line; and certain respite services to support caregivers.  This will help people living with dementia and their caregivers have access to education and support, such as training programs on best practices for caring for a loved one living with dementia. The GUIDE Model also provides respite services for certain people, enabling caregivers to take temporary breaks from their caregiving responsibilities. Respite is being tested under the GUIDE Model to assess its effect on helping caregivers continue to care for their loved ones at home, preventing or delaying the need for facility care.

Services are provided in your home, Assisted Living Facilities, or Memory Care Facilities.  Unfortunately, the GUIDE Model is not available to those living in Long Term Care or a Skilled Nursing Facility/Nursing Home at this time.

Per CMS, “The GUIDE Model’s intended beneficiary population is community-dwelling Medicare fee-for-service beneficiaries, including beneficiaries dually eligible for Medicare and Medicaid, living with dementia.” 

To qualify for the GUIDE Model, you must meet all of the following criteria:

• You must have a diagnosis of dementia, confirmed by a clinician

• You must have Medicare as your primary payer

• You must not reside in a Long-Term Care Nursing Home or Skilled Nursing Facility

• You must be enrolled in Medicare Parts A and B

• You must not be enrolled in Medicare Advantage, Medicare Part C Plans, including Special Needs Plans and PACE

• You must not be enrolled in Hospice

• The GUIDE Model has two start dates for participating providers.  The first group launched on July 1, 2024.  Hospice & Community Care is part of the New Program Track and will begin offering the GUIDE services on July 1, 2025.

• We currently offer, and will continue to offer, Palliative Care services.  Patients living with dementia and their caregivers may still benefit from visits with our Palliative Care providers until we are able to officially offer the GUIDE services on July 1, 2025.  See our “Palliative Care” tab or reach out to us for more information on what Palliative Care can do for you.

• The GUIDE Model is paid for fully by Medicare Part B.  Medicare Advantage plans do not cover this service.

• Typically, under Medicare’s traditional fee-for-service plan, you would have a 20% coinsurance, cost sharing for Medicare Part B physician services (sometimes covered by your supplementary insurance).  This 20% cost sharing is waived for those participating in the GUIDE Model for the Model’s services.  (You may still have this coinsurance for other medical visits not associated with the GUIDE Model, such as other specialists and your primary care provider.)

• Medicare will also cover up to $2,500 per year in respite care.  For more information, see the tab labeled “Tell me more about the respite care services.”

Under the GUIDE Model, you may receive:

• Individualized comprehensive assessment and care plan based on your needs and goals

• 24/7 access to a support phone line

• Caregiver training, education, and support services

• Respite services, up to an annual cap

Respite services may be offered in your home at 4-hour increments.  CMS designates a per 4-hour increment rate, and Medicare will pay for this service up to an annual maximum of $2,500.  Once you meet the annual maximum, you must pay out of pocket for any additional caregiving services you wish to utilize. 

• The “annual year” runs July 1st – June 30th, so your respite benefit resets each year on July 1st.

• Other options for respite care may be offered at a later date.  We will update with further information if this changes.

• If you receive Community Long Term Care (CLTC) caregiver services through Medicaid, you can receive both the GUIDE respite services and the CLTC services as long as they do not overlap.  Per CMS: “The GUIDE Respite Services are intended to be additive to, not duplicative of, any Medicaid respite care benefit offered to dually eligible beneficiaries.”

• Similar to our Palliative Care services, this Model will provide you and your loved one an added layer of support to your existing medical team.  However, the support provided through this Model is specialized to dementia care and aims to alleviate the stresses of caring for those living with dementia while improving quality of life for the person living with dementia. 

• The Hospice & Community Care GUIDE Team will communicate with your primary care provider as needed to promote continuity of care.

• CMS recognizes the caregiving burden and the unpaid time required to care for someone living with dementia and is conducting this Model as an eight-year test to measure outcomes, with plans to run the program until at least 2032.  Data will be shared with CMS through surveys sent periodically throughout the span of the next few years to track the benefits patients and caregivers experience through this Model and to better serve beneficiaries in the future. 

• First step, reach out and contact us.  You may also choose to speak with your primary care provider or another specialist provider and ask them to send a referral to Hospice & Community Care.  We would need some background medical information to get you started: Demographics, History and Physical to include diagnoses, Latest Visit Note(s), and Medication List.

• We would then complete a phone call to assess and determine eligibility for the GUIDE Model or Palliative Care.  If we feel you would meet the criteria, we would schedule an Initial Comprehensive Assessment Visit.

• After this visit and Initial Comprehensive Assessment, Hospice & Community Care would notify CMS of your wishes to voluntarily align with our program for the GUIDE Model. 

• Should CMS accept your eligibility, they would notify Hospice & Community Care of your alignment to our program, and we would commence GUIDE support and services.

Contact our Palliative Care Team, we might still be able to help support you!  Palliative Care treats the symptoms associated with chronic illnesses.  Our providers can assist you and your loved ones in Advanced Care Planning, coping with the stress of chronic illnesses, helping to alleviate the symptoms of chronic illnesses, helping you understand the pros and cons of some treatments, among other support.  Unfortunately, we do not offer respite services for those not under the GUIDE Model, but our team can assist in connecting you to resources that might be available. 

• CMS Innovation Models: GUIDE Model Website:

  https://www.cms.gov/priorities/innovation/innovation-models/guide

• GUIDE Information for Patients and Caregivers CMS Document:

  https://www.cms.gov/files/document/guide-model-patient-caregiver-fs.pdf

• GUIDE Model CMS Overview Factsheet:

  https://www.cms.gov/priorities/innovation/media/document/guide-dementia-fs