Guiding an Improved Dementia Experience

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The Guiding an Improved Dementia Experience (GUIDE) program is an innovative dementia care model developed by the Centers for Medicare and Medicaid Services (CMS). This program is designed to improve the lives of individuals living with dementia and their caregivers by providing a comprehensive, coordinated approach to care. The GUIDE model emphasizes better communication between primary care providers and specialists, caregiver education and support, and ensuring access to care for all patients and families affected by dementia.

The Trager Institute was selected through a competitive national process to implement this model, making it one of the few organizations to participate in this eight-year CMS demonstration project. The program offers services at no cost to eligible participants, aiming to improve dementia care delivery while testing a sustainable payment model that supports these wraparound services.

The GUIDE program is centered around the following core components:

  • Improved Communication: The model promotes enhanced collaboration between primary care providers, specialists, and families, ensuring that care is cohesive and coordinated.
  • Caregiver Support: A strong focus on caregiver education, emotional support, and skill-building helps caregivers manage the challenges of dementia care.
  • Access to Health Care: The program ensures that all eligible individuals and families, regardless of background or resources, have access to essential dementia care services.
  • Respite Care: Providing relief for caregivers through respite care services, allowing them time to rest and rejuvenate.

Eligibility Criteria

To qualify for the GUIDE program, individuals must meet the following criteria:

  • Diagnosed with dementia by a healthcare provider
  • Enrolled in Medicare Parts A and B as their primary payor
  • Not currently enrolled in hospice care
  • Not residing in a long-term nursing facility

Services Offered

The GUIDE program offers a comprehensive range of services designed to support both individuals with dementia and their caregivers:

Comprehensive Assessments
Participants will undergo thorough health evaluations, including cognitive testing and a home safety assessment (conducted either through a home visit or via telehealth).

Care Planning and Coordination
Personalized care plans are developed in collaboration with the patient's healthcare team, ensuring that all aspects of the individual’s care are addressed in a patient-centered approach.

Support and Access
Participants have 24/7 access to their care team for assistance and guidance, providing peace of mind and immediate support when needed.

Medication Management
Regular medication reviews ensure that patients are using medications safely and effectively, with adjustments made as necessary to optimize treatment.

Respite Care
The program provides respite care services for caregivers, allowing them to take breaks from caregiving duties and manage their own well-being.

Caregiver Support and Education
Caregivers receive personalized support through one-on-one assistance, skill training, support groups, and resources such as the Flourishing Embrace app, designed to provide ongoing education and connection.

The Interdisciplinary Care Team

The GUIDE program’s success is driven by a team of experienced, interdisciplinary professionals who collaborate to provide comprehensive care for both patients and caregivers. This team includes:

  • Geriatricians
  • Advanced Practice Registered Nurses (APRNs)
  • Nurses
  • Neuropsychologists
  • Social Workers
  • Care Navigators
  • Chaplain

This integrated team approach ensures that all aspects of dementia care are addressed, offering the highest level of support for individuals and their families.

Transitioning to GUIDE: What to expect

For current patients

Current patients at the Trager Institute’s brain health programs who qualify for GUIDE can transition seamlessly into the model. A dedicated care navigator will guide the transition process.

For new patients

New patients will begin by scheduling an appointment with a healthcare provider to determine eligibility. A care navigator will contact the patient and family prior to the appointment to explain the program and answer any questions.

Once approved for GUIDE, patients and families can expect a personalized care experience, including:

  • Development of a customized care plan
  • A home visit for a safety assessment
  • Connection to respite care services as needed