By Myles Starr

Current U.S. government healthcare plans are failing to provide adequate services for patients with dementia, who face high rates of hospitalization, emergency department visits, post-acute care utilization, and poor management of other co-occurring conditions, according to the Centers for Medicare & Medicaid Services (CMS). Furthermore, their caregivers and communities are burdened by an inefficient health services administration model that results in frequent caregiver burnout and the removal of patients from their homes to expensive nursing homes. In an effort to address these intertwined problems, CMS is launching the Guiding an Improved Dementia Experience (GUIDE) Model nationwide.

“The GUIDE Model focuses on creating an integrated [treatment] pathway that offers comprehensive assessments … 24/7 access to a support line and additional supports for caregivers,” said a CMS spokesperson. “By defining a standardized care delivery approach that is managed by a patient navigator, people living with dementia and their families can receive person-centered care that is tailored to their needs.” 

GUIDE participants will be Medicare Part B-enrolled providers who opt-in and agree to meet the standards required by the model, which include the maintenance of an interdisciplinary medical team (including a care navigator) and use of an electronic health record platform that meets the standards for Certified Electronic Health Record Technology. To increase flexibility, if a provider can’t provide one of the requirements, they are entitled to contract with other Medicare providers to deliver services. CMS will provide a monthly per-beneficiary payment under the model.

The patient navigator is the linchpin of the program, according to a CMS spokesperson. Patient navigators will serve as a link between the clinical healthcare system and community-based providers ensuring access to:

• an interdisciplinary team that will identify the beneficiary’s primary care provider and specialists and outline the care coordination services needed to manage the beneficiary’s dementia and co-occurring conditions, including medication reconciliation and management. (At the participant’s discretion, the interdisciplinary team may also include additional members, such as a pharmacist, social worker and behavioral health specialist.);
• training programs on best practices for caring for a loved one living with dementia;
• respite services, which enable caregivers to take temporary breaks from their responsibilities; and
• referrals for services and supports such as meals and transportation.

The program’s greatest benefit is that it supports the goals and preferences of patients and their families to keep patients in the community. There is also a secondary financial benefit for taxpayers. “The model is expected to reduce federal expenditures on hospitalizations and post-acute care,” the CMS spokesperson said. Additionally, “expected savings will come from reduced long-term nursing home placement through a reduction in federal Medicaid spending on the Federal Medical Assistance Percentage.” As a result of these savings, individual states may also experience reduced expenditures on long-term care.

CMS will release a GUIDE request for applications on Sept. 15. The model will launch on July 1, 2024, and run for eight years. For family members and providers interested in the program, CMS created a “journey map” to show how the model would work in practice.