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CMS is now accepting applications for the Guiding an Improved Dementia Experience (GUIDE) Model. Eligibility requirements and additional model details can be found in the Request for Applications (RFA) (PDF). Interested applicants should submit their application via web portal by Tuesday, January 30, 2024 at 11:59 PM EST.

Through the GUIDE Model, CMS will test an alternative payment for participants that deliver key supportive services to people with dementia, including comprehensive, person-centered assessments and care plans, care coordination, and 24/7 access to a support line. Under the model, participants will assign people with dementia and their caregivers to a care navigator who will help them access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations.

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When used over time, respite services have been found to help unpaid caregivers continue to care for their loved one at home, preventing or delaying the need for facility care. The model is also designed to reduce Medicare and Medicaid expenditures primarily by helping people with dementia to remain at home, and reducing hospitalization, emergency department use, the need for post-acute care as well as long-term nursing home care.

Participants in the GUIDE Model will establish dementia care programs (DCPs) that provide ongoing, longitudinal care and support to people living with dementia through an interdisciplinary team. GUIDE participants will be Medicare Part B enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, who are eligible to bill for Medicare Physician Fee Schedule services and agree to meet the care delivery requirements of the model.

In order to have sufficient model participation and improve the recruitment of diverse beneficiaries, CMS will also recruit organizations that do not currently offer comprehensive dementia care or have prior experience with alternative payment models. CMS will support model participation for these organizations by providing technical assistance and learning support as well as a pre-implementation year to prepare for model participation.

The eight-year model will offer two tracks: one for established programs and one for new programs. Established programs must have an interdisciplinary care team, including a care navigator, use an electronic health record platform that meets the standards for Certified Electronic Health Record Technology, and meet other care delivery requirements as outlined in the RFA. New programs must not be operating a comprehensive community-based DCP at the time of model announcement and will have a one-year pre-implementation period to establish their programs.

CMS will actively seek out the participation of eligible organizations that provide care to underserved communities for participation in the GUIDE Model. CMS will offer a variety of financial and technical supports to ensure that participating safety-net providers can develop their infrastructure, improve their care delivery capabilities, and participate successfully in the model.

GUIDE will also include a focus on beneficiaries with dementia who are dually eligible for Medicare and Medicaid and, as with other patients supported by the model, help them to remain safely in their homes for longer.

Yes, practices in ACO REACH and SSP are eligible to participate in the GUIDE Model. Beneficiaries in those programs are also eligible to voluntarily align to a GUIDE participant while remaining aligned to ACO REACH, Shared Savings Program ACOs and other total cost of care CMS models. The GUIDE Model is designed to be compatible with other CMS models and programs that provide health care entities with opportunities to improve care and reduce spending.

Not all applicants are guaranteed participation in the model. CMS will need to consider factors critical to ensuring a robust evaluation of the model. CMS may also deny individual clinicians or any other individual or entity participation in the GUIDE Model based on the results of a program integrity review.

There is not an option to apply to the GUIDE Model as a Partner Organization. Entities interested in becoming a Partner Organization should work directly with applicants or GUIDE Participants. CMS plans to release a list of GUIDE Participants accepted into the model in Summer 2024.

Yes, model participants may contract with community-based organizations that deliver community-based services and supports in order to deliver respite services and to support other care delivery requirements in the model.

For a Medicare beneficiary to receive services under the model, they will need to find a health care provider that is participating in the GUIDE Model in their community. CMS will publish a list of model participants on its website in the Summer of 2024. A Medicare beneficiary could then visit a model participant, and after consenting to receiving services from the participant, CMS would be able to confirm whether the beneficiary meets the model eligibility requirements before aligning them to the participant.

The GUIDE Model is not a total cost of care model and does not have requirements around specific drug treatments. A beneficiary will not be disqualified from the model based on their Alzheimer's treatment and/or medication.

The GUIDE Model is not a shared savings or total cost of care model, it is a condition-specific longitudinal care model. In general, GUIDE Model participants will be paid a monthly dementia care management payment (DCMP) for each beneficiary. The GUIDE Model is designed to be compatible with other CMS accountable care models and programs (e.g., ACOs and advanced primary care models) that provide health care entities with opportunities to improve care and reduce spending.

The model will pay participants a per beneficiary per month (PBPM) amount, known as a dementia care management payment (DCMP), for providing care management and coordination and caregiver education and support services to beneficiaries and caregivers. DCMP rates will be geographically adjusted and adjusted by a Health Equity Adjustment (HEA) and a Performance Based Adjustment (PBA) to incentivize high-quality care. The GUIDE Model will also pay for a defined amount of respite services for a subset of model beneficiaries.

Model participants will use a set of new G-codes created for the GUIDE Model to submit claims for the monthly DCMP and the respite codes. Each model tier will have a different DCMP rate to reflect the fact that covered services and care intensity will vary across the tiers. Respite services will be paid up to an annual cap of $2,500 per beneficiary and will vary in unit costs dependent on the type of respite service used.

The GUIDE Model Participant will bill for the per beneficiary per month DCMP and respite services. The GUIDE Model Participant will work with the partner organizations to determine any payment arrangement. The participant will be responsible for having contracts and other arrangements in place with their partner organizations to pay for any services that those partner organizations are providing to their aligned beneficiaries. CMS will not pay partner organizations for services under the GUIDE Model, as partner organizations are not model participants.

The primary model payment under the GUIDE Model is a per-beneficiary, per-month care management payment called the Dementia Care Management Payment (DCMP). The DCMP will replace fee-for-service payment for some existing Medicare Physician Fee Schedule (PFS) services, including chronic care management and principal care management, transitional care management, advance care planning, and technology-based check-ins. Therefore, the GUIDE Participant will not be able to bill separately for these services for aligned beneficiaries. The GUIDE Model is not a total-cost-of-care model, so all services not included in the DCMP will continue to be billed under traditional fee-for-service. Additional information, including a complete list of duplicative codes, is available in the Request for Applications (Table 8, pg. 35). CMS may add or remove codes over time to reflect changes in PFS billing codes.

The GUIDE care delivery requirements provide beneficiaries and caregivers with flexibility when receiving care. CMS anticipates that nearly all model components could be delivered virtually, which will allow model access for beneficiaries and caregivers in rural areas and other communities without access to specialized dementia care. One example of this is the Comprehensive Assessment care delivery requirement, which is an assessment that may be performed via telehealth or in-person based on the preference of the beneficiary and/or caregiver. Caregiver education and support are additional components of the model that may also be delivered virtually. The only in-person visit requirement is the in-home visit requirement for certain beneficiaries when they are first aligned to a model participant.

On an annual basis, CMS will publish a methodology paper that will show the technical specifications and benchmarks for the performance measures. The methodology papers will be made available to GUIDE Participants 30 days before the applicable performance year. Details on the caregiver burden measure benchmark, which will not be phased in until later in the model, will be available in a future methodology paper.

GUIDE Participants that do not meet measure benchmarks will receive a negative adjustment on the performance-based adjustment (PBA) of the Dementia Care Management Payment (DCMP) but will be permitted to continue participating in the model.

Health-Related Social Needs, or HRSN, are used to describe individual-level social needs and are individual-level adverse social conditions that negatively impact a person's health or health care. HRSN collection and referrals will be part of the model's broader care delivery requirements for comprehensive assessment and referral for social services and supports. Participants will annually report aggregated, domain-level data from HRSN screening domains such as food insecurity, housing instability, transportation needs, utility difficulty, and interpersonal safety, starting after the first model performance year. e24fc04721