The Guiding an Improved Dementia Experience (GUIDE) Model is an 8-year voluntary nationwide model test that aims to support people with dementia and their unpaid caregivers. The GUIDE Model focuses on comprehensive, coordinated dementia care and aims to improve the quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities for as long as possible, rather than go into a nursing home. By providing no cost care coordination services to patients, we take the burden off of caregivers, providers, and their staff.

GUIDE IS NOT a Medicare Managed Care Program and does not replace the medical care of the individual.

Patient services include:
• Care coordination services needed to help manage the beneficiary’s dementia and co-occurring conditions.
• The interdisciplinary care team which will deliver services by creating and maintaining a person-centered care plan, which will include details on the beneficiary’s goals, strengths, and needs; comprehensive assessment results; and recommendations for service providers and community-based social services and supports.
• Care Navigator to help access resources such as home-delivered meals, transportation, home health aide services, primary care physicians and specialists if needed.

Caregiver services include:
• Ongoing monitoring and support via 24/7 access to a support line
• Caregiver skills training
• Respite care in-home or other settings if needed
• Tips for medication management

 

The GUIDE Model’s intended beneficiary population are community-dwelling (can live in personal home, assisted living facility, group home or other community setting) Medicare fee-for-service beneficiaries, including those dually eligible for Medicare and Medicaid, living with dementia. Eligible beneficiaries must meet the following criteria:
• Diagnosis of dementia, confirmed by a medical provider.
• Has Medicare as their primary insurance plan.
• Enrolled in Medicare Parts A and B (not enrolled in Medicare Advantage, including Special Needs Plans and PACE}.
• Not enrolled in Medicare Hospice benefit.
• Does not reside in a long-term nursing home.

Service areas include:
• Five boroughs of NYC: The Bronx, Brooklyn, Manhattan, Queens, and Staten Island
• Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester Counties

Let’s talk about what you need. And what you want.

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