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CMS Announces GUIDE – a New Dementia Care Model Designed for Participation by a Range of Providers

Health care providers furnishing dementia care should take note of a new payment model called Guiding an Improved Dementia Experience (GUIDE), which was announced by the Centers for Medicare & Medicaid Services (CMS) on July 31, 2023. GUIDE is designed to improve dementia care, reduce strain on unpaid caregivers, and help people with dementia remain in their homes and communities. GUIDE is an eight-year model offered nationwide, and a wide range of Medicare Part-B providers and suppliers are eligible to participate. (Only durable medical equipment and laboratory suppliers are excluded.) As detailed below, providers participating in GUIDE (GUIDE Participants) receive monthly per-beneficiary, per-month payments, can bill for respite care services, and are eligible for one-time payments to support infrastructure.

Overlap with other CMS Payment Models

While many CMS alternative payment models prohibit or restrict model participants from concurrently participating in different payment models, GUIDE is compatible with other CMS payments models, including the Medicare Shared Savings Program or MSSP; Realizing Equity, Access, and Community Health or REACH; and advanced primary care models such as Primary Care First and the new Making Care Primary Model. GUIDE is not a multi-payor model, and the target population is limited to Medicare fee-for-service beneficiaries, including beneficiaries dually eligible for Medicare and Medicaid.

GUIDE Requirements

GUIDE Participants must maintain an interdisciplinary team that includes (i) a care navigator with training in dementia assessment and care planning and (ii) a clinician with dementia proficiency as recognized by experience caring for adults with cognitive impairment, experience caring for patients 65 years or older, or specialty designation in neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology. GUIDE Participants can, but are not required to, include additional members in the interdisciplinary team, such as pharmacists and behavioral health specialists. GUIDE will include a standardized approach to dementia care that includes staffing considerations, services for beneficiaries and unpaid caregivers, and quality standards. GUIDE Participants must provide caregiver training and support services, including access to a support line and connections to community-based providers. GUIDE also requires screening of beneficiaries for psychosocial needs and health-related social needs.

GUIDE has two tracks – (i) one for GUIDE Participants already providing dementia care that are prepared to immediately implement GUIDE’s care delivery requirements and (ii) one for GUIDE Participants without a comprehensive dementia care program that are interested in scaling support to implement a dementia care program. GUIDE Participants in the latter track will receive technical assistance and support during a pre-implementation year to enable them to prepare for participation in GUIDE.

GUIDE Payment Structure

GUIDE Participants can receive the following payments:

  • Infrastructure Payment. GUIDE Participants are eligible for a one-time, lump-sum infrastructure payment to support program development activities.
  • Per-Beneficiary Per-Month Payment. GUIDE Participants will receive a monthly per-beneficiary, per-month payment for providing care management and coordination and caregiver education and support. These monthly payments will be adjusted by a health equity adjustment and a performance-based adjustment.
  • Respite Care Payment. GUIDE Participants will be able to bill Medicare for respite services for beneficiaries with a caregiver and moderate to severe dementia, up to an annual cap. Respite services are temporary services to beneficiaries in their home, at an adult day center, or at a facility that can provide 24-hour care in order for caregivers to have temporary breaks from their caregiving responsibilities. The goal is to help caregivers continue to provide care, preventing or delaying the need for facility care.

Next Steps

CMS is offering a Guide Model Overview Webinar on August 10, 2023. Health care organizations interested in participating in GUIDE can submit to CMS a letter of interest for GUIDE, which CMS is accepting through September 15, 2023. CMS will release a GUIDE Request for Applications in the fall of 2023, and GUIDE will launch on July 1, 2024.

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Rachel Yount is a Mintz attorney who focuses her practice on health care industry transactions. Her clients include hospitals, health systems and plans, physician organizations, and pharmacy benefit managers.