The GUIDE Model for Dementia Care
Guiding an Improved Dementia Experience. A CMS innovation model providing coordinated dementia care through traditional Medicare, with a trusted partner at every stage of the journey.
Support for patients and caregivers.
The GUIDE Model combines clinical care with practical support at home, so families can focus on what matters most.
It is available through traditional Medicare Parts A and B.
Dedicated Care Navigator
One point of contact for coordination and referrals.
Customized care plan
Developed by a physician-led team around the patient’s stage of dementia.
Annual caregiver respite benefit
Up to $2,563 per year for eligible caregivers.
24/7 helpline
Reach a care team member or navigator at any hour.
Medication management
Ongoing medication review and safety checks.
Is your loved one eligible?
The GUIDE Model is available to Medicare beneficiaries who meet the criteria below. Please refer to the CMS guidelines for complete insurance eligibility details.
Dementia diagnosis
Has been diagnosed with Alzheimer’s disease or a related dementia by a qualified clinician.
Traditional Medicare
Enrolled in Medicare Parts A and B. Not enrolled in a Medicare Advantage plan, a PACE program, or hospice.
Not in a long-term nursing home
Does not live in a long-term skilled nursing facility. Home and assisted living settings are accepted.
Medicare as primary payer
Medicare must be the patient’s primary health insurance payer for GUIDE services.
Seven core services
Care navigation
A committed Care Navigator works with the clinical team to manage communication, appointments, and medications, plus referrals to community services.
Care management
An interdisciplinary team develops a customized care plan with ongoing monitoring and regular updates for the patient’s stage of dementia.
Respite services
Caregivers could qualify for respite care to help prevent burnout and maintain their own health, up to $2,563 per year.
Caregiver education
Training, education, and support for caregivers, with Care Navigators to coordinate clinical and non-clinical resources.
24/7 support
Beneficiaries and caregivers can reach a care team member or navigator through a 24/7 helpline.
Training and support groups
Access to classes, content, and support groups on dementia care for patients and families.
Medication management
Frequent evaluation of prescribed medications, with guidance on schedules and safety.
Annual caregiver respite benefit available through the GUIDE Model
Caregiver burnout is one of the most serious challenges in dementia care. The respite benefit provides financial relief so family caregivers can rest and recover.
- Spouses providing daily care at home
- Adult children managing care from a distance
- Families managing behavioral symptoms
- Caregivers at risk of their own health decline
How to enroll in the GUIDE Model
Contact our team
Call the clinic nearest you and ask about GUIDE. We will answer your questions.
Eligibility review
We verify Medicare enrollment, diagnosis documentation, and location.
Consent and enrollment
Complete a brief Medicare consent form.
Meet your Care Navigator
Your Care Navigator introduces the team and schedules the initial assessment.
Care begins
Your personalized plan launches with visits, monitoring, caregiver support, and 24/7 access.
GUIDE Model FAQ
Is there any additional cost for GUIDE?
GUIDE services are covered under traditional Medicare, with no additional cost beyond normal Medicare cost-sharing. A supplemental plan is not required, though one may further reduce out-of-pocket costs. Please verify your coverage with our team.
What types of dementia qualify?
All types of dementia can qualify, including Alzheimer’s disease, vascular dementia, Lewy body dementia, frontotemporal dementia, and mixed dementia, as long as the diagnosis is documented and Medicare eligibility requirements are met.
My loved one has a Medicare Advantage plan. Do they qualify?
GUIDE currently requires traditional Medicare (Parts A and B) as the primary payer. Patients on Medicare Advantage or PACE plans are not eligible. Call us to talk through your specific situation.
Can my loved one qualify if they are in an assisted living facility?
Yes. Assisted living residents can be eligible. The model is not available to patients residing in long-term skilled nursing facilities.
How do we access the 24/7 helpline?
Once enrolled, patients and caregivers receive a direct helpline number for urgent clinical questions, behavioral crises, or general support at any time.
How is GUIDE different from regular visits?
GUIDE is a coordinated program designed for people with dementia. Beyond medical visits, it includes a dedicated Care Navigator, caregiver education and respite services, 24/7 access, and structured connections to community resources.
Your trusted partner in dementia care.
Our team is ready to answer your questions, confirm eligibility, and guide you through enrollment.
GUIDE is a Centers for Medicare & Medicaid Services model. Eligibility and benefits are determined by Medicare. This page is for general information.