# CMS GUIDE Model: Lessons Learned By An Established Track Program At End Of Year One

## TL;DR

The CMS GUIDE Model is a new dementia care program that shows early success in supporting patients and caregivers through team-based care, but faces challenges in implementation.

## Contribution

The paper provides insights into the first-year implementation of the CMS GUIDE Model as an Established Track program in a large health system.

## Key findings

- The program enrolled 158 beneficiaries with 35% utilizing respite services and 9% disenrolling, mostly due to expiration or hospice.
- An adaptable team-based approach and structured processes were critical for success, including weekly data reviews and care coordination.
- Challenges included workflow adjustments, system constraints, and the need for external partnerships and additional resources.

## Abstract

‘Guiding an Improved Dementia Care Experience’ (GUIDE) is a CMS Innovation Center pilot program implemented January 2024, as an alternate payment model for interprofessional teams to provide comprehensive dementia care for people living with dementia and their caregivers. Program criteria encompass screening and recruitment, comprehensive and home safety assessment, ongoing beneficiary monitoring, data collection/management/reporting, respite, caregiver supports, etc. We report first-year implementation and evolution as an ‘Established Track’ program in a large integrated health system in a major metropolitan area. To date, the program has enrolled 158 beneficiaries and their caregivers; 19% low, 73% moderate, 8% high complexity. Average age of beneficiaries 79 years, caregiver relationship 53% child, 35% spouse, 10% other. Over 35% of eligible beneficiaries have utilized respite services. Approximately 9% have disenrolled, the majority (64%) expired/hospice. An adaptable team-based approach has been a critical strategy for success. Helpful processes that have evolved include structured recurring meetings, weekly review of data and submissions, care coordination and scheduled monitoring of required care-delivery services. Education and outreach with all stakeholders (e.g. interprofessional healthcare providers, lay community) is essential. Internal challenges have included need for ongoing adjustment of workflows and processes, and system constraints on structuring database/submission/reporting. Additional challenges include changing program requirements, recognizing and addressing the need to supplement internal resources (e.g. home visits, respite care), and identifying and establishing partnerships with external entities. These successes and challenges may significantly impact effectiveness of this pilot model program. Providing additional resources for this vulnerable population requires a true interprofessional, multidisciplinary approach.