If you have had a loved one suffer from dementia, you know the emotional, physical, and financial toll of this terrible disease. With advancements in dementia treatment, however, there is renewed hope on addressing this disease and increasing emphasis on fostering innovative care models.
A central pillar of this effort is the Guiding an Improved Dementia Experience (GUIDE) model, announced by the US Department of Health and Human Service’s Centers for Medicare & Medicaid Services (CMS) in July 2023. This initiative—a new voluntary, nationwide alternative payment model—is designed to support Medicare beneficiaries with dementia, as well as their caregivers.
GUIDE Model Background
Individuals with dementia often suffer from multiple chronic conditions, and they also experience high rates of depression and other behavioral and psychological symptoms. These patients typically experience fragmented or poorly managed care, resulting in high hospitalization, emergency department (ED) visits, and post-acute care utilization rates.
Family members and other unpaid caregivers provide significant financial, personal care, and healthcare management assistance to dementia patients, at great personal, financial, and emotional expense. As a result, these caregivers experience high levels of stress and depression, which negatively affects their own overall health and impacts their ability to continue to provide care to their loved ones.
In 2023, dementia affected 6.7 million Americans and about one in nine (10.7%) Medicare beneficiaries suffered from dementia. With these numbers expected to double by 2060, CMS’s goal in implementing the GUIDE model is to improve the quality of life for those living with dementia, while also reducing the strain on their unpaid caregivers.
Further, the GUIDE model aims to reduce Medicare and Medicaid expenditures by enabling individuals with dementia to remain safely in their homes for longer by preventing or delaying nursing facility placement and reducing hospitalization and ED usage rates.
What Does the GUIDE Model Entail for Patients and Caregivers?
The GUIDE model, a pilot program that will formally launch on July 1 and run for eight years through July 2032, will feature financial support and clinical guidance for a comprehensive package of person-centered assessments and care plans, care coordination and care management, caregiver education and support, and respite services.
First, the GUIDE participants, which are Medicare Part B-enrolled suppliers, such as physician groups and clinics (but excluding durable medical equipment suppliers and labs), are required to maintain an interdisciplinary team (IDT) consisting of, at minimum, a “Care Navigator” and a clinician with specialized dementia proficiency.
The GUIDE participants will assign Medicare beneficiaries with dementia and their caregivers who elect to participate in the GUIDE model to a Care Navigator. The Care Navigator’s role is to help their assigned beneficiaries access the GUIDE model’s clinical and non-clinical support services (e.g., meals and transportation provided through community-based organizations), answer questions about dementia care, and serve as a caregiver resource. Care Navigators are not intended to provide direct clinical care or caregiver services.
In addition, the GUIDE model will provide caregivers with evidence-based training, education, and support services, including programs on best practices for caring for a loved one with dementia. Currently, there is no coordinated resource for caregivers who have a loved one with a dementia diagnosis, resulting in variable levels of caregiver support.
The GUIDE model is intended to close that gap. Patient and caregiver well-being will also be supported through access to a 24/7 support line and respite care resources, which will allow caregivers to take temporary breaks from their demanding caregiving responsibilities—similar to respite care services currently covered by the Medicare hospice benefit.
How Do Healthcare Providers Participate in the GUIDE Model?
While many patients with advanced dementia might typically be cared for by home health agencies or—if terminally ill—by hospices, the GUIDE model focuses on the period of care before the disease exacerbates. Medicare Part B-enrolled suppliers participating in the GUIDE model are required to establish formal Dementia Care Programs (DCPs) that provide ongoing, longitudinal care and support to dementia patients through the participant’s IDT.
At the DCP’s discretion, the DCP may include additional providers—such as pharmacists or behavioral health specialists—in the IDT. Those DCPs that cannot or choose not to meet GUIDE model care delivery requirements independently may also contract with other Medicare providers and suppliers (referred to as “Partner Organizations”) to furnish GUIDE model services. These Partner Organizations will usually consist of hospices, home health agencies, and nurse staffing agencies.
The GUIDE model consists of two separate tracks—one for established DCPs, or those applicants ready to implement GUIDE care delivery requirements immediately, and one for new DCPs that are not currently operating a comprehensive program and will benefit from a one-year pre-implementation period with additional GUIDE model supports to establish their program. Notably, CMS is actively seeking GUIDE model participants that support underserved communities and is offering financial and technical support to help these organizations develop their care capabilities for dementia patients.
Under the GUIDE model, DCPs will receive a per-beneficiary-per-month amount (referred to as the “Dementia Care Management Payment”) for providing care management, care coordination, and caregiver support services. Additionally, DCPs will be able to bill for respite services, up to an annual respite cap amount. New program track providers will also be eligible for a one-time, lump sum payment to support development of their care infrastructure.
Legal Considerations in the GUIDE Model
The GUIDE model necessarily relies on significant home-based care services, so it is likely that most DCPs will engage Partner Organizations to handle much of the day-to-day patient and caregiver support, with the Part B physician group providing medical oversight and direction. While this comprehensive home-based care approach is similar to hospice and home health, the focus is on medical treatment, limiting exacerbations, and ensuring that caregivers are equipped with the tools to address the myriad needs of their loved ones.
The hope of the GUIDE model is that this comprehensive, wraparound care will result in substantial Medicare and caregiver cost savings, better outcomes for patients with dementia, improved quality of life for caregivers, and limitations on facility-based care. It also presents an opportunity for post-acute care providers to work closely with medical providers to furnish coordinated care outside of the typical Medicare construct.
Still, this opportunity presents certain legal risks associated with referrals. Providers and suppliers, whether operating a DCP or serving as a Partner Organization, should continue to carefully vet their relationships to ensure they do not run afoul of federal laws, including the Anti-Kickback Statute and Stark Law.
Of course, in addition to those regulatory and GUIDE model program compliance considerations, healthcare providers should be mindful of apportioning other legal risks between GUIDE participants and Partner Organizations. For instance, which party is responsible for the safety of caregivers who enter patient homes? What if there is a patient care or abuse issue? Will the GUIDE participant’s medical malpractice coverage apply to Partner Organization staff? These details should be carefully addressed in a care coordination or similar agreement between these parties.
If you have questions on the GUIDE model or your organization’s role in the GUIDE model, contact the authors or your Morgan Lewis lawyer, and stay tuned for additional information on the GUIDE model as the program begins to roll out.