GUIDE Program

The GUIDE Model was developed by the Centers for Medicare & Medicaid Services (CMS) to improve the quality of life for people with dementia and reduce the emotional, physical, and financial strain on caregivers. Through monthly Medicare payments to participating providers, the program delivers a comprehensive package of services designed to:

• Help people with dementia stay safely in their homes and communities
  
• Provide family caregivers with support, training, and relief
  
• Reduce hospitalizations, ER visits, and the need for nursing home care
  

Address social and emotional needs through community partnerships

As a GUIDE participant, we provide a structured, evidence-based care experience that includes:

• Personalized Dementia Care Plan
  Tailored to each patient’s unique medical, behavioral, and social needs, developed by an interdisciplinary team.
  
  
• Assigned Care Navigator
  A dedicated guide who coordinates care, helps access community resources, and offers ongoing check-ins and support.
  
  
• 24/7 Support Line
  Caregivers have round-the-clock access to trained dementia care professionals for questions or urgent concerns.
  
  
• Caregiver Education & Training
  Access to evidence-based programs on managing symptoms, communication strategies, safety, and more.
  
  
• Respite Care Services
  Temporary relief care—either at home, in an adult day center, or in a facility—so caregivers can rest, attend to their own health, or simply take a break. This is a Medicare-covered benefit within the GUIDE program and is shown to help prevent caregiver burnout and delay institutional care.
  
  
• Screening for Social and Emotional Needs
  We assess for unmet health-related social needs (like access to food, transportation, or housing), and connect families with local support resources.
  
  

Community Referrals
Help connecting to non-clinical services such as meal delivery, transportation, home safety modifications, and financial support organizations.

• Structured, Coordinated Dementia Care
  A standard-of-care approach that ensures consistency, quality, and whole-person care for patients and families.
  
  
• Support for the Entire Caregiving Journey
  From early signs to more advanced dementia, GUIDE offers the tools, guidance, and support to navigate every step with confidence.
  
  
• Caregivers Get Relief and Resources
  With education, 24/7 support, and Medicare-funded respite care, family caregivers gain the strength and capacity to continue caring at home.
  
  
• Designed to Keep Loved Ones at Home
  The GUIDE model helps delay or prevent nursing home placement—keeping individuals in familiar surroundings, close to those they love.
  
  

Health Equity Built In
Extra support is available for those in underserved or rural communities, including individuals who are dually eligible for Medicare and Medicaid.

The GUIDE Model is available to Medicare beneficiaries diagnosed with dementia who are living in the community (not in a long-term care facility), along with their unpaid caregivers. Our team will guide you through the enrollment and care planning process.