Dementia Care Model Announced
Today’s blog is written by Rebecca Rye.
On July 31, CMS announced a new nationwide voluntary payment model, the Guiding an Improved Dementia Experience (GUIDE) model, in an effort to improve quality of life for people with dementia and their caregivers. The model seeks to reduce dementia-related Medicare and Medicaid spending by improving the care experience for people with dementia and better empowering caregivers, ideally reducing the need for emergency room care and delaying the need for full time, residential care.
CMS will release full model details with the request for applications later this fall. In the meantime, we have answers to your initial questions about the model!
What is the GUIDE model?
The GUIDE model uses a multi-pronged approach to providing longitudinal care for Medicare beneficiaries with a dementia diagnosis:
- Participating beneficiaries will receive care from an interdisciplinary care team, including but not limited to a dementia-proficient clinician and a care navigator. Dementia-proficient clinicians include those who have at least one of the following three characteristics:
- At least 25% of the clinician’s patient panel is made up of adults with cognitive impairments, including but not limited to dementia.
- At least 25% of the clinician’s patient panel is aged 65 or older.
- The clinician has a specialty designation of neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology.
- Care navigators who have received standardized training will be assigned to people with dementia participating in the model to assist them and their caregivers with accessing services and supports. These supports may be both clinical and non-clinical services, including utilizing existing community resources for day-to-day needs like transportation and meal delivery.
- Participants in the program will provide unpaid caregivers with training programs on how best to provide care for people living with dementia, along with access to ongoing evidence-based education.
- Program participants will help unpaid caregivers to coordinate respite services to help relieve the stress that accompanies caring for people with dementia.
The GUIDE model will utilize a voluntary alignment process for Medicare beneficiaries. Model participants must inform potential beneficiary participants about the model and services available, and document that the beneficiary or their legal representative consents to participate. Beneficiaries that are eligible for both Medicare and Medicaid are able to participate in the model.
What organizations are eligible to participate in the model?
Eligible participants include Medicare Part B enrolled providers and suppliers who are able to bill for services under the Medicare Physician Fee Schedule and who agree to the care delivery requirements of the model. Durable medical equipment and laboratory suppliers are excluded from the model. If an interested organization cannot meet all model requirements alone, they may contract with other Medicare providers or suppliers to meet care delivery requirements.
What tracks are available for participants?
There are two tracks for model participants:
- The established program is designed for participants that already have substantial experience providing care to beneficiaries with dementia. Participants in the established program should be prepared to implement the full range of model requirements immediately.
- The new program is designed to broaden the field of potential participants and allow organizations that are not experienced in providing dementia care but have an interest in entering the field. New program participants cannot have an existing dementia care program. They must provide a detailed plan to implement model requirements and will have a one-year pre-implementation period to establish services.
When will the model run?
Established program participants will launch programs on July 1, 2024. New programs will begin their pre-implementation period on the same date, then launch their programs on July 1, 2025. The model will run for eight years.
How will payments for the GUIDE model work?
The model includes three avenues for payment:
- Infrastructure payments will be available for participants in the new program track. These one-time, lump-sum payments will help to support program development.
- Participants will receive per beneficiary, per month payments for providing care management, care coordination, and caregiver training and support services.
- Participants are able to receive separate payments for respite services provided to beneficiaries who have moderate to severe dementia and an unpaid caregiver, up to a yearly cap of $2,500.
Model participants will use a new set of G-codes specific to the GUIDE model to submit claims for the monthly dementia care payments.
How CLA can help
Wondering whether the GUIDE model could be a good fit for your organization? While full model details have not been released, CLA can help to start a conversation about the potential opportunities of the program. Reach out to an advisor today.
Jennifer Boese is the Director of Health Care Policy at CLA. She is a highly successful public policy, legislative, advocacy and political affairs leader, including working in both the state and federal government as well as the private sector. She brings over 20 years of government relations and public policy knowledge with her to CLA. Well over half of her career has been spent dedicated to health care policy and the health care industry, affording her a deep understanding of the health care market and environment, health care organizations and health care stakeholders. Her role at CLA is to provide thought leadership, policy analysis and strategic insights to health care providers across the continuum related to the industry's ongoing transformation towards value. A key focus of that work is on market innovations and emerging payment models. Her goal is to help CLA clients navigate and thrive in an increasingly dynamic health care environment.
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