Webinar Recap: Understanding the CMS GUIDE Model

Key Takeaways:

  • GUIDE’s caregiver support requirements will require a distinct care plan for caregivers and will require organizations to train staff accordingly.

  • Strategic patient selection for referral into the program will be critical for providers, especially for risk-bearing entities.

  • Comprehensive home assessments will extend beyond medical evaluations to address social determinants of health and caregiver dynamics.

Now that applications for the CMS GUIDE Model have been submitted and accepted participants have been notified, what’s next?

As a follow-up to our introductory webinar on Understanding the CMS GUIDE Model last year, we brought our panelists back to share the latest information as the program ramps up.

In partnership with Pearl Health and Jukebox Health, Bahamia Ulysse, ianacare’s Director of Caregiver Navigator Program moderated and facilitated an educational conversation with Dr. Cam Berg of Pearl Health, Dhruv Vasishtha, an ianacare advisor, and Dan Weinrieb of Jukebox Health.

Catch up with our key learnings and takeaways from the discussion below, and hear insights in much more detail with the full recording here.


1. Identifying Patients for Referral

Identifying the right patients for the GUIDE program is critical, but not straightforward. Providers need to conduct comprehensive cognitive assessments and carefully review patient data, including diagnosis codes, cognitive and physical functional, and social determinants of health, to determine eligibility.

Relying solely on diagnosis codes won’t be sufficient – the GUIDE program requires a more nuanced approach to patient selection.

“It is Pearl's perspective that at least 50 percent of the guide eligible patients do not presently have an ICD that would crosswalk to what CMS has said constitutes eligibility. Why is that many patients who are actually actively managed for neurologic conditions. are not diagnosed with the dementia symptoms that are derivative from that.”

2. In-Home Assessments Are About More Than Safety

The in-home assessments requirement will go beyond just clinical factors to also evaluate the patient’s social determinants of health, home environment, and caregiver needs.


Integrating the clinical assessment team and the in-home assessment team, such as occupational therapists is key to getting a holistic view of the patient’s situation and developing the right care plan.

"We can go beyond what we're seeing in the E. M. R. The occupational therapist that we're deploying into the home to really perform these comprehensive evaluations. They're looking at the entire person, as well as any caregivers that are supporting the care recipients, and they're looking at the environment for safety, for other social needs, the SDOH codes, all of those things...”

3. A New Type of Care Plan – Centered on the Caregiver

Caregiver support is a central component of GUIDE, requiring a dedicated care plan focused on the caregiver’s personal goals and needs, not just the patient’s clinical care plan. This is a shift from traditional approaches, and places a groundbreaking focus on supporting the caregiver with respite, training, and a dedicated 24/7 support line, which will all be crucial to keeping the patient safely at home for as long as possible.

"There are two big differences that I see on the caregiver support requirements for guide than the status quo. So I think that the first is that, the navigation and the care plan for the caregiver is not a patient care plan. It is a caregiver care plan. And I think that that is quite different for how many organizations have typically worked with family members”

4. Enhancing the Role of the Caregiver

GUIDE participants will require access to comprehensive education and training resources, both for caregivers and the care navigation team supporting them.

Providing this support at scale throughout the program duration will be important to ensure caregivers are equipped to manage the patient’s needs and the care team can effectively coordinate the patient’s care.

5. Partnership and Building Infrastructure

Organizations in both the established and new GUIDE tracks are actively working to build out the required partnerships, operating models, and best practices, even if they are not launching until 2025, in order to be prepared. This proactive approach will help ensure a smooth implementation when the program goes live. Reach out to ianacare to learn more about partnering to fulfill the program’s caregiver support requirements– including the 24/7 support line.


Throughout the webinar, the audience sent in lots of great, thoughtful questions. Our panelists didn’t have a chance to answer each question live, so we wanted to feature some of those questions below, with answers from our experts:

Attendee Poll Question:

If you applied and were approved to GUIDE, is your organization part of the established or new track?

Which of the required services are most GUIDE participants having difficulty fulfilling in-house? How can 3rd parties add value?

Dhruv Vasishtha: I think that it just depends on what you currently don’t have in-house. So if you’re a home health agency, you likely do not have the in-house provider capabilities to do great cognitive impairment assessments. So that is one category that a lot of folks are asking for.

If you are a neurology clinic, you likely haven’t had much of a reason to have a deep PT, OT, home modification, home assessment capability.

And then I think if you are a health system that got approved or an ACO that got approved, you may not have much in the way of a caregiver engagement strategy. So I think that those span the gamut. Cam really highlighted something, which is, I think right now, most entities don’t have great data analytics and data science capabilities to say, on day one, who are we going to really focus on for guide?

That is a very common conversation I have, which is, what clinical data, what claims data, would we be analyzing? What are the filters that we should be putting in place just to say, okay, the first month of GUIDE, here are the 30 people that, we think our practice should try to enroll and engage in the program and then kind of can do that continuously.

If a 24/7 Support line staffed by a nurse would be too "expensive", what are the necessary qualifications to staff this line?

Dhruv Vasishtha: The GUIDE model has a list of training topics that they want caregiver care navigators to be educated on, but there is no licensure requirement

How different GUIDE asseement is to SDOH assessement? Or it is encomposing/supplimenting SDOH assessement?

Dhruv Vasishtha: Encompassing of it but probably not as focused / deep on just doing say a PRAPARE social risk assessment

Dan Weinrieb: I would also add that the in-home assessments can be completely customized and can include assessment questions that are aligned with the program goals as well as the provider’s goals.

Interested in learning more about GUIDE and how we can help your organization apply? 

Book a free consultation today.

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