By Patricia Noonan, MBA, RN, CCM, CDP, FCM
In July 2023, CMS announced it would launch and test a new alternative payment model to improve dementia care across the country beginning in July 2024. Under the direction of the Center for Medicare & Medicaid Innovation (CMMI), the GUiding an Improved Dementia Experience (GUIDE) Model will target the Medicare dementia population by focusing on care management services for people diagnosed with dementia and their caregivers. The goal of the GUIDE Model according to CMS is “to improve the quality of life for people living with dementia, reduce strain on their unpaid caregivers, and enable people living with dementia to remain in their homes and communities.”
Why Focus on Dementia Care?
There are currently more than 6 million people living with a dementia diagnosis in the United States which negatively impacts the quality of life for not only dementia individuals but their families. In addition, CMS reports that 95 percent of individuals with dementia often have other chronic conditions such as hypertension and diabetes which cannot be managed over time leading to hospitalizations. The burden of caregiving is significant for families with the total cost of dementia care in the nation currently at $345 billion.
In 2022, consulting firm Healthsperien conducted an analysis that showed a comprehensive dementia care payment model could improve the quality of care, and quality of life for individuals with dementia and their caregivers, and potentially save Medicare and Medicaid nearly $21 billion over 10 years. As a result, in March 2023, the bipartisan bill, the Comprehensive Care for Alzheimer’s Act (S.626) was introduced in Congress with recommendations made by Senators to CMMI urging swift action to implement a dementia care management model in Medicare given the aging population and the need for dementia services. Further, in April 2023, the Biden Administration announced an Executive Order on Increasing Access to High Quality Care and Supporting Caregivers which directed the Secretary of Health and Human Services (HHS) to consider advancing the GUIDE Model.
The GUIDE Model will provide a standard set of care management services from an interdisciplinary team for individuals with dementia and their caregivers that includes a comprehensive assessment, care coordination to community resources, medication management, development of a patient-centered care plan, caregiver education and training, care transitions support, ongoing monitoring & support, 24/7 access to the care team, and respite care services. An important component of the GUIDE Model includes Medicare Part B providers working closely with an interdisciplinary care team, including a “care navigator” who can provide regular outreach, education, problem-solving, and connect the caregiver to support services within the community. Other important features of the GUIDE Model include screening for SDOH, measuring caregiver burden and quality of life, and establishing an equity plan for participants in underserved communities.
The GUIDE Model provides a tremendous opportunity for case managers to play a vital role in this new value-based alternative payment model that CMMI will test for eight years. Providers approved for the GUIDE model will receive a per beneficiary per month payment to cover the program care management services for Medicare dementia beneficiaries and their caregivers. ACO Reach and ACO Medicare Shared Savings Program (MSSP) providers can also participate in the GUIDE Model. Finally, case managers are perfectly positioned to contribute to the GUIDE Model with the competencies needed to deliver high-quality, patient-centered care that is “grounded in professional practice and advocacy” adding value to the dementia population and their caregivers.
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Bio: Patricia Noonan, MBA, RN, CCM, CDP, FCM, is a passionate advocate and mentor for case managers with over twenty years working in case management leadership roles. She has served on the CMSA Board, CMSA Foundation Board, and currently serves on the CMSA Finance Committee and CMSA Sponsorship Committee. She is experienced in population health: ACO, Employee, Medicare and Commercial program development. She has published articles and presented on important case management topics. Patricia received the CMSA CMOY Award in 2021, CMSA AOSE Award in 2017, and was recognized as a Case Management Fellow (FCM) by CMSA in 2022.
1. Centers for Medicare & Medicaid Services. Guiding an Improved Dementia Experience (GUIDE) Model. (2023). https://www.cms.gov/priorities/innovation/innovation-models/guide
2. Centers for Medicare & Medicaid Services. Biden-Harris Administration Announces Medicare Dementia Care Model. (July 2023). https://www.cms.gov/newsroom/press-releases/biden-harris-administration-announces-medicare-dementia-care-model
3. Alzheimer’s Association. Medicare to Improve Dementia Care for Individuals Living with Alzheimer’s Disease, Caregivers. (2023). https://www.alz.org/news/2023/cms-dementia-care-caregivers-initiative-guide
4. Alzheimer’s Association. 2023 Alzheimer’s Disease Facts and Figures. (2023). https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
5. CMSA Standards of Practice for Case Management. (2022). https://cmsapmg.wpenginepowered.com/sop22/