GUIDE Program
Your GUIDE multidisciplinary team: (left to right):
Julie McCormick, CRNP Zaheer Khan, MD Sue Cheek, Social Worker, LBSW
ABOUT THE GUIDE PROGRAM
In July of 2024, the Center for Medicare and Medicaid Services (CMS) introduced the Guiding an Improved Dementia Experience (GUIDE) Model. This is a new model of care that aims to support people with dementia and their unpaid caregivers. The model will run for eight years.
The Center for Elder Care is the only primary care clinic in Alabama that has been approved to be a GUIDE participant. This model provides Medicare coverage for comprehensive, coordinated dementia care with the goal of improving the quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities. It will achieve these goals through Medicare payments for a comprehensive care coordination, caregiver education and support, and respite services.
Persons living with dementia (PLWD) enrolled in the GUIDE model will be assigned a Care Navigator and will also have an in-home visit. Those with moderate or severe dementia may be eligible for in-home or adult day care respite service benefits.
WHO IS ELIGIBLE FOR GUIDE?
To be eligible for the CMS GUIDE Model, the patient must meet the following criteria:
- Has a confirmed diagnosis of dementia
- Has Medicare Part A&B as primary insurance (not under a managed plan
- Is not enrolled in Medicare hospice benefit
- Is not living in a long-term nursing home
- Lives within the Center for Elder Care service area
ENROLLMENT PROCESS
- If you are an established patient with the Center for Elder Care, an appointment will be set up for a comprehensive assessment with Dr. Khan.
- If you are NOT an established patient with Dr. Khan and would like to be a new patient, a new patient appointment will be set up to establish care. The GUIDE assessment will be your second visit.
- The patient/caregiver will complete a required pre-visit packet prior to the assessment and bring it to the office either before or on the day of the comprehensive assessment.
- The comprehensive assessment will be performed by Dr. Khan.
- Our staff will send information from the appointment to Medicare to determine benefits.
- Once approved, our Care Navigator will reach out to make an in-home visit and establish a plan of care.
- The patient and caregiver will receive continued coordinated care as long as they are still eligible for the program.
***At this time, we are requiring that our GUIDE patients have Dr. Khan/Center for Elder Care as their primary care provider (PCP). We feel that this helps us to take care of the whole patient, enables us to change medications that may be causing cognitive problems, and manage other comorbidities that may be contributing to dementia/cognition.
GUIDE BENEFITS
HOME VISITS
CMS requires GUIDE enrollees to have a one-time home visit in cases of moderate or high complexity dementia. A home visit helps ensure that you and your caregiver get additional support and evaluate if any safety measures are recommended. At this time, our social worker, Sue Cheek, will get to know the patient as well as the caregivers, assess the need for resources, and establish a plan of care.
During the home visit, we assess:
- The home environment
- How you function in your home, including performing your personal care tasks
- Other environmental, social, and behavioral factors
- Any resources that you may need
Sue, your care navigator, will talk with you and walk around your home to evaluate safety and fall risk.
We ask that the patient AND caregiver be present for the home visit. Sue will call ahead of time to find a time and day that is most convenient.
RESPITE FUND
Through GUIDE, Medicare offers up to $2500 a year for eligible GUIDE enrollees so caregivers can take a break when needed.
Respite service support comes from local in-home respite providers, adult day centers, and 24 hour/day respite facilities. The Center for Elder Care partners with community-based organizations and home care agencies to provide these services.
Patients enrolled in the GUIDE Model with moderate to high complexity dementia who have a caregiver are eligible for respite services. The respite services fund is available to eligible GUIDE enrollees after completing their initial visit and being aligned within the GUIDE Model.
Funds renew on July 1 of each year throughout the program. You cannot carry over unused funds to the following year.
GUIDE FAQs
