The US Centers for Medicare & Medicaid Services (CMS) recently announced a new, voluntary and nationwide test model designed to support two rapidly growing demographic groups: people living with dementia, and their unpaid caregivers. The Guiding an Improved Dementia Experience (GUIDE) Model will focus on dementia-care management and aims to improve the quality of life for people living with dementia. The model will offer care coordination and care management for individuals living with dementia, while providing education, support and respite services for their caregivers.
Approximately 6.7 million Americans currently live with Alzheimer’s disease or another form of dementia, and that number is expected to more than double by 2060. To address the needs of the growing dementia population and their caregivers, the GUIDE Model seeks to bridge the gaps in care for people with dementia.
Some key components of the model include:
Model design and purpose: The model will be voluntary and run for eight years (through July 1, 2032) and will be offered nationwide. In this model, Medicare Part B providers (participants) will establish dementia-care programs (DCPs) to provide longitudinal care and support to Medicare beneficiaries living with dementia (beneficiaries), as well as to their family members and other individuals who provide significant amounts of assistance to the beneficiaries (caregivers). The model will be person-centered in its delivery approach and will require participants to provide a defined standardized set of services for beneficiaries and their unpaid caregivers (such services are likely to be defined in the request for applications (RFA) described below, but which has not yet been released). Furthermore, participants are required to form an interdisciplinary care team that must include a care navigator who has received requisite training in dementia, assessment and care planning, as well as a clinician with dementia proficiency.
Beneficiary eligibility criteria: Beneficiaries are eligible to receive services under the GUIDE Model if they (i) have dementia (as confirmed by a clinician practicing within the model), (ii) are enrolled in Medicare Parts A and B and have Medicare as their primary payer, (iii) are not enrolled in the Medicare hospice benefit and (iv) do not reside in a nursing home. Beneficiaries will be placed in one of five “tiers” based on their disease stage and level of caregiver strain. Each additional tier represents increased beneficiary needs, care intensity and payment.
Provider participation: Medicare Part B enrolled providers/suppliers that are eligible to bill for Medicare physician fee schedule services are eligible to participate in the GUIDE Model. It should be noted, however, that durable medical equipment and laboratory suppliers are not eligible to participate. To improve the recruitment of diverse beneficiaries, CMS will recruit organizations that do not offer comprehensive dementia care or have experience with alternative payment models. CMS will provide technical assistance and other support to these organizations to prepare them for participation in the model.
Tracks: The GUIDE model will consist of two tracks, one for established programs and one for new programs. To qualify as an established program, the participant program must (i) have an interdisciplinary care team, (ii) use an electronic health record platform that meets the standards for certified electronic health record technology and (iii) meet care-delivery requirements to be outlined in the RFA. A new program is a program that is not operating a comprehensive, community-based dementia-care program at the time of the model’s announcement. New programs will have a one-year pre-implementation period to establish their programs and will have a performance period that starts on July 1, 2025. The performance period for established programs will begin on July 1, 2024.
Payment methodology: The model encompasses three types of potential payments: an infrastructure payment, a per-beneficiary-per-month payment and a respite-care payment.
The infrastructure payment is a one-time, lump-sum amount given to participants in the new-program track to support activities related to program development.
CMS will make a per-beneficiary-per-month payment, also known as a dementia care management payment (DCMP), to all participants regardless of track. This payment is intended for providing care management and coordination as well as caregiver education and support services. It is not yet clear if the DCMP applies to new programs during their implementation period. The DCMP rates will be adjusted by two factors: a health equity adjustment (HEA) and a performance-based adjustment, both of which aim to incentivize high-quality care.
Finally, participants can also bill for respite services, which are temporary services provided to a beneficiary in order to give the unpaid caregiver temporary breaks from caregiving. Coverage for respite services is limited to beneficiaries with moderate to severe dementia and who have a caregiver. These respite services are subject to an annual cap.
Compatibility with other models: Since the GUIDE Model is a condition-specific longitudinal care model, CMS has stated that it is designed to be compatible with other CMS accountable care models and programs (e.g., accountable care organizations (ACO)s and advanced primary care models).
The GUIDE model will launch on July 1, 2024. CMS is currently accepting letters of interest (LOI) for the model through September 15, 2023, and will release an RFA for the model in fall 2023. Further information regarding the model will become available upon the release of the RFA.
Please contact the authors with any questions you may have regarding the GUIDE Model.