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GUIDE Model Guidance: A Better Dementia Patient Experience for Everyone

Projections show that as many as 14 million people will be living with dementia in the United States by 2060. In fact, a Columbia University study found nearly 10% of Americans 65 and older have dementia while 22% have some form of mild cognitive impairment. Improving the treatment of dementia patients and the overall experience their family goes through is at the foundation of the Center for Medicare and Medicaid Services’ (CMS) new GUIDE Model. The model is the focus of a new ebook with insights from Ryan Klaustermeier, MSN, RN, Vice President of Professional Services. He believes that community-based palliative care providers are a natural fit for this new approach.

What is the GUIDE Model?

The Guiding an Improved Dementia Experience (GUIDE) Model was introduced in July 2023 is meant to focus on improving the quality of life for patients, reduce the burden on unpaid caregivers and keep dementia patients in home and community settings. The model will run for eight years beginning in July 2024.

“Though the GUIDE Model can be provided by any entity which is willing to meet the criteria of the demonstration, community-based palliative care is likely the best existing clinical model to utilize it,” writes Klaustermeier.

Organizations participating in model will have to provide 24/7 access to phone support and a care navigator that patients and their family have all available resources that align with the individuals’ needs.

These needs, and how they will be met, are the result of the core elements of the GUIDE Model:

  • Person-centered care
  • Interdisciplinary collaboration
  • Family support
  • Accessing community resources
  • Quality improvement initiatives by the participating providers

Eligible beneficiaries for this demonstration need to have a diagnosis of dementia from a provider participating in the model, be enrolled in Medicare Part A and B, and may not be living in skilled long-term care, or enrolled in Medicare Advantage, Medicare hospice or in PACE (Program of All-Inclusive Care for the Elderly).

Why Community-Based Palliative Care is Ideal for GUIDE

Klaustermeier notes in the ebook that the underpinnings of the model are ideally suited for community-based palliative care providers to step in to fill this vital role.

“Individuals living with dementia often experience care that is not coordinated, which results in a high frequency of emergency departments and hospitalizations,” writes Klaustermeier. “Fragmented care results in poor patient and family outcomes.”

He also points out that community-based palliative programs are ideal because palliative care is already focused on delivering patient-centered care that extends to the family and caregivers. And that palliative care is meant to provide care that addresses the entire person, including mind, body, and spirit.

The application period for the initial set of participating providers closed in January 2024 but with a multi-year demonstration, it is possible that new applications will be accepted if the model shows signs of success.

To read more about the GUIDE Model and its application in community-based palliative care, download our ebook.

Axxess Palliative Care, a cloud-based palliative care software, was built for flexibility with streamlined workflows from intake to claim submission.


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