Dementia is a huge challenge for patients, families, and many of our Coalition members, impacting nearly 7 million Americans today. That’s why we are excited by the CMS Innovation Center’s recent release of the Guiding an Improved Dementia Experience (GUIDE) Model dementia care demonstration program, an eight-year, national program that features many of our requests to CMMI, such as: support for the unpaid family caregiver, the integration of community-based organizations, an upfront payment for infrastructure, and advance care planning. The GUIDE model also meets each of our 11 Core Principles for Care Models (see table below). We look forward to continuing to work with the Innovation Center on the rollout of the GUIDE model and on opportunities to integrate support for people facing serious illness into future demonstrations.
C-TAC Principle
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GUIDE Dementia Model
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Person and family unit of care, QOL.
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Yes, QOL is a key metric, and the model will measure if for both person with dementia and family caregiver (via validated Zarit caregiver burden tool). Family education and support is also required.
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Care is inclusive – reducing inequities and disparities and removing barriers to access and to quality care.
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Yes, there will be a health equity payment adjustment and social and community-based services will be promoted via the required navigator.
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Physical, social, psychological, and spiritual needs are assessed on an ongoing and standardized basis.
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Yes, a comprehensive assessment is required annually for patients in the model that will explore all these areas.
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| A care plan is developed, using shared decision-making, based on those needs and the person’s individual goals and preferences.
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Yes, care planning is a key component of the model and patient/family preferences will be honored in regard to care, respite, etc.
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Care is provided by a qualified core interdisciplinary team, with additional team members as needed. |
Yes, the team must include a navigator and experienced dementia provider and can be supplemented by other roles as needed. PMPM payment will cover even non-billable roles.
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Care is accessible 24/7 (using technology, as appropriate) and available throughout the continuum of a serious illness (including in the home when appropriate). |
Yes, this is a key model requirement and technology, or call lines can be used as long as they provide meaningful support after hours.
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Care is comprehensive, coordinated, with seamless transitions, and with integration of clinical and community-based services and supports for the person and family caregiver(s).
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Yes, care coordination is a requirement of the model, social services will be promoted via navigators, measures include total cost of care and nursing home placement.
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| Payment is value-based, available to qualified organizations of any size, and includes risk adjustment, upfront investment, accountability, standardized metrics, and quality improvement, and covers both clinical and social services.
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Yes, the payment is a PMPM with an upfront infrastructure payment for those on the new provider track/from underserved communities.
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Tally |
11/11! |
Call to Action
Interested programs should submit a letter of intent (LOI) by September 15th. The LOI is non-binding and programs can later apply without having submitted one, but it gives CMMI an idea of who is interested in participating.
