What is The CMS GUIDE Model?

Picture of Dhruv Vasishtha

Dhruv Vasishtha

Dhruv Vasishtha sits on the ianacare clinical advisory board. He is a healthcare product leader and was most recently the founding SVP Product at firsthand, a GV backed tech-enabled value based care provider that supports individuals living with serious mental illness. Prior to that Dhruv led product at PatientPing, a national care coordination platform that was acquired by Appriss Health (now known as Bamboo Health)

Key Takeaways:

  • GUIDE is a groundbreaking program prioritizing caregiver support to enhance the quality of life for dementia patients.
  • The program introduces a unique structure with pillars including:
    • Care coordination
    • Caregiver support , training, and education
    • Respite services
  • The program will begin in July 2024 and evaluate based on care coordination, patient quality of life, caregiver burden, utilization, and long-term nursing home stay rates.

Intro to CMS’s GUIDE Model

Earlier this year, CMS announced the GUIDE model, or “Guiding an Improved Dementia Experience” model. This voluntary model aims to improve the quality of life for dementia patients and their informal/family caregivers with an approach to care delivery that prioritizes care coordination and caregiver support.

This program is the first of its kind and marks a shift toward recognizing the influence and impact informal/family caregivers can have on the health & medical outcomes of patients in their care. 

Unlike past and existing CMS programs which have historically been aimed at reducing the cost of care, the intent of the GUIDE program is not to create a shared savings or evaluate reduction in total cost of care. It is purely focused on prioritizing and financing caregiver support.

The development of the GUIDE model underscores CMS’s realization that family caregivers play a concrete and crucial role in shaping health outcomes. By offering enhanced support to family caregivers, the program aims to alleviate some of the burdens of caring for patients with Alzheimer’s, resulting in better care for patients.

Lifting these burdens improves the physical and emotional health of caregivers, which has translated to improved health outcomes. Patients whose caregivers are depressed, burned out, or fatigued experience a 73% increase in ED utilization &  $1,937 higher medical costs.

When family caregivers are involved and engaged in care plans, hospital readmissions decrease by 25%. These figures emphasize the pivotal role that caregiver support plays in enhancing overall health outcomes for patients.

Why Now?

The GUIDE model is uniquely focused on dementia because the disease takes a significant toll on caregivers. With limited effective treatment options, those caring for these Americans are left managing ADLs (activities of daily living) as well as major changes to the behavioral and mental health of their loved ones.

These caregivers can’t go unrecognized much longer. More than 6.7 million Americans will suffer from dementia by 2023, and as the baby boomer generation ages, 14 million will be affected by dementia by 2060. 

In addition, many patients with dementia suffer from other co-existing conditions like diabetes, hypertension, and musculoskeletal disorders.

This intensifies the responsibility and burden placed on caregivers and leads to exacerbated costs when those caregivers become burnt out by a lack of respite and proper support resources.

Unfortunately, a lack of support for caregivers often means dementia patients don’t receive the necessary care, leading to increased costs and premature admissions to long-term nursing homes and memory care facilities. This is particularly true for patients and caregivers in lower socioeconomic situations.

The Biden administration has consistently acknowledged the work of family caregivers as a crucial part of our healthcare and social systems and made the prioritization of these efforts clear with a new executive order released earlier this year.

Understanding the CMS’s GUIDE Program

Now that we’ve laid the groundwork for the “why”, let’s focus on the “what”. What exactly is GUIDE going to do to build caregiver support?

The program is focused on improving quality of life, reducing caregiver burden, and enabling people with dementia to stay in their homes longer using the pillars below:

  • Care Coordination & Management: Patients will have an interdisciplinary team to create a person-centered care plan to understand the status of their disease, and provide continuous monitoring and care.
  • Caregiver Support & Education: Participants must deliver caregiver support in the form of training, education, and support groups, as well as a dedicated, expert Care Navigator focused on facilitating access to the services and support they need– both clinical and non-clinical.
  • Respite Services: Some participating caregivers will be eligible for free respite services amounting to $2,500 per year.

The most novel pillar in this program’s structure is caregiver support. Each participant must ensure they have the content, expertise, and resources in place before enrolling in the program, something that has not been traditionally required in most clinical settings. These requirements are comprehensive:

  • Navigation: A dedicated expert is there to help facilitate communication, appointments, medication needs with the clinical care team, and referrals to community-based services including meal and transportation assistance.
  • 24/7 support line: Beneficiaries and caregivers must have access to a member of their care team or Care Navigator using a 24/7 helpline
  • Training: On-demand access to comprehensive educational classes, content, and support groups on a wide array of topics related to dementia caregiving.
  • Medication management: The clinical team regularly reviews prescribed medication as needed, while care navigators provide tips for patient and caregiver to successfully adhere to medication regimens.

The Mechanics of the GUIDE Model

The last piece of understanding the GUIDE model is the how. How it will run, how patients become eligible, and how CMS and participants can understand the impact and effectiveness.

The program will officially begin in July 2024 and will last eight years. Eligible patients must:

  • Have a dementia diagnosis
  • Have Medicare as their payer
  • Be enrolled in Medicare Parts A & B (not Medicare Advantage or PACE)
  • Not be enrolled in Medicare hospice benefit
  • Not be residing in a long-term nursing home (assisted living facilities are accepted)

There will be periodic evaluations throughout the program. For many existing value-based providers, this is a new opportunity to reduce the costs of care using the resources provided by the GUIDE model

Participants are required to collect and report data and will be evaluated based on:

  • Care Coordination and Management: High-risk medications (eCQM/CQM)
  • Patient quality of life: Quality of life outcome (Survey-based)
  • Caregiver Support/Burden: Zarit Burden Interview (Survey-based)
  • Utilization: Total Per Capita Cost (Claims-based)
  • Long-term nursing home stay rate (Claims-based)

In Conclusion

The GUIDE model marks a new chapter in the way our culture acknowledges and addresses all of the non-clinical care deeply impacting clinical outcomes. For too long, the pivotal work of family caregivers has been hidden and taken for granted by our healthcare and social systems. This model serves as a first step toward placing tangible value on that work.

By integrating them into the care team and supporting their participation, we can improve the holistic care experience for patients, improving their quality of life and keeping them at home longer.

Our work at ianacare is dedicated to recognizing and supporting this critical role. To date, we have served over 42k members with hands-on, proactive, and comprehensive support as they care for their loved ones. Our solution was built to bridge the gap in home-based care using innovative and scaleable technology alongside a team of expert, dedicated Caregiver Navigators.

To learn more about how we can support participants of the GUIDE program to fulfill their caregiver support requirements, reach out to us at

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