by Kristin Rowan, Editor

On July 1, 204, CMS launched the GUIDE Model and announced that 390 organizations had signed on to participate. The Guiding an Improved Dementia Experience (GUIDE) Model is a voluntary model test amied at supporting people with dementia and their unpaid caregivers (family members).

The GUIDE Model focuses on comprehensive, coordinated dementia care to improve the quality of life for people with dementia. It also hopes to reduce the strain on family caregivers and keep patients in their homes and communities longer. Medicare payments cover the package of care coordination, care management, caregiver education and support, and respite care.

The GUIDE Model aims to address the key drivers of poor-quality dementia care in five ways:

• • Defining a standardized approach to dementia care delivery for model participants – this includes staffing considerations, services for people with dementia and their unpaid caregivers, and quality standards.
  • Providing an alternative payment methodology to model participants – CMS provides a monthly per-beneficiary payment to support a team-based collaborative care approach.
  • Addressing unpaid caregiver needs – the model aims to address the burden experienced by unpaid caregivers by requiring model participants to provide caregiver training and support services, including 24/7 access to a support line, as well as connections to community-based providers.
  • Respite services – CMS pays model participants for respite services, which are temporary services provided to a beneficiary in their home, at an adult day center, or at a facility that can provide 24-hour care for the purpose of giving the unpaid caregiver  temporary breaks from their caregiving responsibilities.
  • Screening for Health-Related Social Needs – model participants are required to screen beneficiaries for psychosocial needs and health-related social needs (HRSNs) and help navigate them to local, community-based organizations to address these needs.

Aspects of GUIDE designed to improve health equity include:

• • Requiring participating providers to implement HRSN screenings and referrals.
  • Offering financial and technical support for development of new dementia care programs targeted to underserved areas with less access to specialty dementia care.
  • Annual reporting by participants on progress towards health equity objectives, strategies, and targets.
  • Using data from the model to identify disparities and target improvement activities.
  • A health equity adjustment to the model’s monthly care management payment to provide additional resources to care for underserved beneficiaries.

PocketRN gives patients, families, and caregivers a “nurse for life,” closing the gap between healthcare and care at home. This whole-person support allows patients and their caregivers to have access to medical care through their virtual nurse, who establishes a relationship with the patients and families.

On January 13, 2025, PocketRN announced a Strategic Partnership with Nevvon to pilot the GUIDE Model.

Nevvon is a global home and health care training tech company that certifies caregivers for continuing education. The app-based learning allows caregivers to go at their own pace, simplifying compliance, and empowering agencies to deliver exceptional care.

On January 15, 2025, PocketRN announced a Strategic Partnership with Right at Home to provide support to eligible Medicare beneficiaries with dementia.

Right at Home is a nationwide provider of in-home care and will provide care and safety assessments for eligible beneficiaries to evaluate the safety of the home environment, the ability of the patient to manage and function at home, and report back to PocketRN any other factors that might impact the patient and their family caregiver.

Later today, PocketRN will announce a National Strategic Partnership with with Assisting Hands® Home Care to test the care model. 

Assisting Hands provides in-home care to seniors, individuals with disabilities, and people recovering from illness or injury. The agency has a significant portion of their client base with a dementia diagnosis. Their franchise system has locations across the United States.

Existing models and studies using PocketRN have shown up to a 30% reduction in urgent care visits, ER visits, and hospitalizations. The company is focusing on finding new strategic partners for a greater understanding of patient engagement from a home care agency standpoint.

Nancy gave us this inside information: 

The three recent announcements are just the beginning. Expect more announcements in the next 30-60 days and then continuing throughout the year.

PocketRN will eventually be applying the GUIDE Model in agencies, patients already using PocketRN, and direct referrals across all 50 states.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing.  Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

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