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The GUIDE Model will promote high-quality dementia care by defining and requiring GUIDE Participants to use a comprehensive, standardized care delivery approach for providing care to aligned beneficiaries and their caregivers. The GUIDE care delivery approach includes
a standardized package of services that the GUIDE Participant must provide to beneficiaries and their caregivers as relevant to the beneficiary’s preferences and needs based on the person-centered plan (“GUIDE Care Delivery Services”),
an interdisciplinary care team to deliver these services, and
a standardized training requirement for care navigators who are part of the interdisciplinary care team.
CMS will require the GUIDE Participant to provide GUIDE Care Delivery Services to its aligned beneficiaries, as applicable and appropriate to each individual beneficiary’s needs.
Table 3 summarizes the GUIDE Care Delivery Services under nine domains.
See Appendix B for detailed requirements of each care delivery domain.
| Domain | Required Activities by Domain |
|---|---|
| Comprehensive Assessment | • Initial comprehensive assessment that includes clinical, behavioral and psychosocial, and advance care planning domains, as well as caregiver needs and capabilities and home visit |
| • Reassessments for beneficiary and caregiver at least once per year | |
| Care Plan | • Develop a comprehensive person-centered care plan that addresses all assessment domains and is led by the beneficiary |
| • If the GUIDE Participant is not a primary care practice, ensure the primary care provider has access to the beneficiary’s person-centered care plan | |
| 24/7 Access | • Beneficiary has 24/7 access to an interdisciplinary care team member or help line (may be a 3rd party vendor during off-duty hours) |
| • Help line must be available to receive ad hoc one-on-one support calls from the caregiver | |
| Ongoing Monitoring and Support | • Care navigator is primary point of contact |
| • GUIDE Participant maintains a minimum contact frequency with the beneficiary and/or their caregiver. Minimum contact requirements vary by model tier, as follows: |
â—¦ Beneficiaries with a caregiver o Low complexity dyad tier: at least quarterly o Moderate complexity dyad tier: at least once a month o High complexity dyad tier: at least once a month
â—¦ Beneficiaries without a caregiver o Low complexity individual tier: at least once a month
o Moderate to high complexity individual tier: at least twice a month | | Care Coordination and Transitional Care Management | • If the GUIDE Participant is not a primary care practice, the GUIDE Participant must coordinate with the beneficiary’s primary care provider • Refer beneficiary to specialists to address co-occurring conditions, as needed • Ensure receipt of information back from specialist to add to care plan • Support the beneficiary in transitions between personal home and care settings | | Referral and Coordination of Services and Supports | • Maintain or have access to inventory of local/community services • Refer and connect beneficiaries to community-based services and supports34 • For dually eligible beneficiaries, coordinate the delivery of any community-based services and supports with beneficiary’s Medicaid HCBS/LTSS case manager, if applicable | | Medication Management and Reconciliation | • Clinician with prescribing authority must review beneficiary’s medications • Any resulting medication changes must be shared and confirmed with the beneficiary’s PCP and other relevant specialists | | Caregiver Education and Support | • Administer a caregiver support program, which must include: ◦ caregiver skills training - dementia diagnosis information ◦ support group services - ad hoc one-on-one support calls • GUIDE Participant must provide dementia diagnosis information and ad hoc support calls directly, but may contract with a vendor or a community-based organization to provide caregiver skills training and/or refer caregivers to external support group services | | Respite | • Referral and coordination of in-home respite care • Option to refer to adult day centers or facility-based respite providers |
The GUIDE Care Delivery Services are the minimum services that the GUIDE Participant is required to offer beneficiaries. The GUIDE Participant must be able to provide the GUIDE Care Delivery Services at varying levels of intensity depending on model tier and the beneficiary’s individual needs.
The GUIDE Participant may offer certain additional services outside of the GUIDE Care Delivery Services, including the in-kind beneficiary engagement incentive permitting GUIDE Participants to use their own funds to provide environmental modifications to the beneficiary’s home.
See section titled, “Authority to Test the Model”, for more information regarding this beneficiary engagement incentive.
As highlighted in Table 3, the delivery of services will be guided by the creation and maintenance of a person-centered care plan, which will detail
the beneficiary’s goals, strengths, preferences and needs,
the results from the comprehensive assessment,
recommendations for service providers and community-based services and supports, including which individual or program is responsible for payment of each service provider, and