The Centers for Medicare & Medicaid Services (CMS) held a Guiding An Improved Dementia Experience (GUIDE) model overview on August 10. CMS deputy director and Center for Medicare and Medicaid Innovation (CMMI) director, Liz Fowler, welcomed participants and emphasized CMMI’s investment in the model and support for people living with dementia and their caregivers.
The overview recording and slides will be available for members soon, and LeadingAge members will have access to a members-only webinar on the GUIDE model with the CMMI team on August 30 at 11 a.m. ET. Registration details are coming soon.
CMMI supports developing and testing innovative health care payment and service delivery models aimed to achieve better care, better community health, and lower costs for the health care system. It works with providers and systems to test and evaluate models for additional reimbursement for participating.
The GUIDE model will test whether a comprehensive package of care coordination and management, caregiver support and education, and respite services can improve the quality of life for people with dementia and their caregivers. The model aims to delay avoidable long-term nursing home care placement and enable more people to remain at home, if that is their preference.
Eligible beneficiaries are those diagnosed with dementia confirmed by attestation from a clinician practicing with a participating GUIDE dementia program. The beneficiary must be enrolled in Medicare A and B—those enrolled in Medicare Advantage plans, including SNPs and PACE, are not eligible. The beneficiary must live in the community, i.e., cannot reside in a nursing home but can reside in assisted living, affordable housing, their own private housing, or an independent living residence. The beneficiary also cannot be enrolled in hospice. Beneficiaries will be voluntarily aligned to the model so must opt in and consent. Duals are eligible.
Who is the GUIDE Model Participant?
The GUIDE model provider participant is a Medicare Part B provider or supplier (except for DME or laboratory suppliers) who is eligible to bill using the Medicare Part B physician fee schedule and agrees to meet the care delivery model requirements. If the GUIDE participant cannot meet the care delivery requirements alone, they may contract with “partner organizations” to meet the care delivery requirements. Partner organizations must be Medicare-enrolled providers or suppliers as well.
A single Medicare Part B provider forms a GUIDE dementia care program (e.g., a multi-specialty practice selects some clinicians to form a dementia care program).
Several Medicare providers (e.g., a geriatrics practice, an occupational therapy practice, and a home health agency) partner together to form a dementia care program.
A Medicare provider (e.g., a PACE organization, a hospice, a home health agency) establishes a new Part B enrolled TIN to form a GUIDE dementia care program.
Organizations can choose certain NPIs within their Part B provider to assign to the GUIDE model. PACE organizations and hospices can be model participants if they have Part B billing capability, but beneficiaries enrolled in PACE and hospice cannot be enrolled in the GUIDE model.
CMMI encourages partnerships with home and community-based services providers – in LeadingAge’s upcoming Aug 30th webinar, we will ask CMMI to discuss what these partnerships can look like for providers who are not Medicare participants – for example, many adult day programs are not Medicare enrolled. CMS leaders were clear in the webinar that existing Medicare providers can add a Part B TIN – but clarification is needed as to whether providers who have never been enrolled in Medicare can enroll in order to participate in the Model.
This participant must have an interdisciplinary team (IDT) that includes, at a minimum, a care navigator and a clinician with dementia proficiency. The clinician must be eligible to bill Medicare Part B evaluation and management codes. Additional members of the IDT are at the participant’s discretion. The care navigator is not required to have specific licensure but must receive dementia-specific training. CMMI will provide some examples of training but will not require specific training to be used.
Dementia proficiency is defined as:
At least 25% of a clinician’s patient panel is comprised of adults with any cognitive impairment, including dementia; or
At least 25% of a clinician’s patient panel is comprised of adults aged 65 or older; or
The clinician has a specialty designation of neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology.
Care Coordination and Management: Beneficiaries in the Model will receive care from an interdisciplinary team. The team will be responsible for offering several care delivery requirements – each individual’s care plan determines their exact mix of services. The care delivery requirements are:
Comprehensive Assessment: both beneficiaries and their caregivers will receive separate assessments to identify needs and a home visit to assess beneficiary safety.
Care plan: beneficiaries receive care plans that address goals, preferences, and needs.
24/7 Access: beneficiaries and caregivers must have access to a call center 24/7 where they can reach out with needs. The 24/7 access helpline can be contracted to a third party or run by the participant organization.
Ongoing Monitoring and Support: Care navigators provide long term help to beneficiaries and caregivers so they can revisit their goals and needs at any time.
Referral and Support Coordination: the care navigator connects the beneficiary and the caregiver to community-based services and supports such as home delivered meals and transportation.
Caregiver Support: caregivers are provided caregiver training and the Model includes respite care (up to a $2500/beneficiary/year cap).
Medication Management: clinician reviews and reconciles medication as needed; care navigators provide guidance on maintaining medication schedule.
Care Coordination and Transition: beneficiaries should receive timely referrals to specialists to address other health issues and the care navigators coordinate care with the specialist.
Caregiver Support and Education: GUIDE participants are required to provide a caregiver support program which must include caregiver skills training, dementia diagnosis education, support groups, and access to a personal care navigator who can help problem-solve and connect the caregiver to services and supports. These offerings can be in person or virtual.
Respite Services: Beneficiaries categorized as having moderate to severe dementia who have a caregiver will be eligible to receive $2,500/beneficiary/year of respite services with no cost sharing. The participant must be able to offer these services in the beneficiary’s home, and can offer them in facility settings that can provide 24/7 care or in medical or social adult day.
The central payment component for the model is a Dementia Care Monthly Payment (DCMP). The DCMP is a per beneficiary per month payment that replaces physician fee schedule billing for certain care management services (e.g., chronic care management).
The DCMP has two adjustments. The first is a performance-based adjustment (PBA) which is a percentage adjustment up or down depending on how participants perform on the model metrics in the previous year. The PBA will calculate five model performance metrics across four domains. We will ask CMMI to be clear regarding which contribute to a downward PBA vs an upward but the domains give some indication.
Domain 1: Care Coordination and Management which will be measured by the use of high-risk medication (NQF endorsed measure 0022).
Domain 2: Beneficiary Quality of Life: Quality of Life outcome (survey based).
Domain 3: Caregiver Support: Zarit Burden Interview (survey-based, under development may not be available at model start).
Domain 4: Utilization: Total Per Capita Cost (Claims based) and long-term nursing stay rate (claims based, under development, may not be available at model start).
The second is a health equity adjustment (HEA) which will be based on beneficiary-level health equity scores based on social risk factors which may include the national area deprivation index, the state area deprivation index, low-income subsidy status, and dual eligibility status.
The last component of the payment is a separate payment for respite services. For moderate to severe dementia beneficiaries with a caregiver, participants can bill up to $2,500/beneficiary/year. The respite payment is separate from the DCMP.
The GUIDE model can be layered into accountable care arrangements and more detail on this will be available in the request for application later this fall.
Model participants will use a new set of G codes to submit claims for the DCMP which is intended to cover the model’s required care delivery activities. CMMI will provide each participant with a monthly beneficiary alignment file with all the aligned beneficiaries, their model tier assignment, and the length of their alignment.
Low Complexity with a caregiver
Moderate Complexity with a caregiver
High complexity with a caregiver
Low complexity, no caregiver
Moderate to high complexity, no caregiver
First 6 months (New beneficiary Rate)
After first 6 months (Established beneficiary payment rate)
New vs Established Practice, Timeline, and Geography
The model will start on July 1, 2024, and run for eight years. For practices already running a dementia practice that meets the model requirements, they will start on July 1, 2024, and run the model for eight years. Practices that are setting up new dementia care practices will have a pre-implementation year from July 1, 2024, to June 30, 2025, and will run the model for seven years. New practices do not have to be ready to provide care at the time of application but will be asked to detail their plan to start a program including staffing, program protocols and workflows, training and development for a referral network, and name a program director.
Programs that are designated as “safety net” providers (determined by the number of dual eligibles and low-income subsidy beneficiaries served) will be eligible for a one-time infrastructure payment to get started. These practices will receive $75,000 in July 2024 to establish the program. LeadingAge will ask CMMI to give more detail on qualifying for the infrastructure payment.
The model will be available in all 50 states and U.S. territories and DC.
A letter of interest (LOI) for the model is due September 15. The LOI is not required for model participation, but is strongly encouraged. You can still apply later in the fall. We will seek clarification on how applicants will be selected to participate.