In what has been considered the most significant shift in recent Medicare policy, the Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model last year.

Home-based care companies are enthusiastically embracing the GUIDE Model, often teaming up with vendors to do so. Care providers already report benefits, including expanded referral networks and improved patient quality of life – and possibly overall cost-savings.

Virtual nursing startup PocketRN is a GUIDE participant and is contracted with franchise personal care company, Right at Home, as a partner organization.

“We were awarded participation in GUIDE for our nurse for life model, which we’ve been developing and building for years, and is focused on providing a dedicated, specialized nurse to older adults and their caregivers as they navigate the complexities of care in the home,” Jenna Morgenstern-Gaines, CEO of PocketRN, told Home Health Care News. “We do this in close partnership with home and community-based services providers, and other health care organizations across the continuum of care. One of our amazing partners is Right at Home.”

Palo Alto, California-based PocketRN partners with home care and home health providers to offer patients personalized, virtual nursing services. The company also works with hospitals, health systems, payers and offers remote patient monitoring.

The GUIDE Model is an eight-year voluntary nationwide program focusing on improving dementia care while keeping people at home. PocketRN is currently in a pilot phase, but will officially go live with GUIDE on July 1.

Through the model, PocketRN also provides care coordination services.

“PocketRN nurses will have discussions with the beneficiary about all the different services they’re receiving and fill in some of the gaps that the family might be dealing with when they have one set of communication from one provider, and different communication from another provider,” Doug Robertson, senior director of government affairs at Right at Home, told HHCN. “That is the goal of GUIDE, to bridge some of those gaps in a disjointed health care system with many different providers,” Doug Robertson, senior director of government affairs at Right at Home, told HHCN. 

PocketRN’s partnership with Right at Home gives the franchise’s clients access to PocketRN’s nurse for life program and allows PocketRN to deliver respite care services.

Based in Omaha, Nebraska, Right at Home provides in-home companionship, personal care and support to seniors and adults with disabilities seeking to live independently through more than 750 locations across the U.S. and five other countries.

While Right at Home is not an official GUIDE participant, its partnership with PocketRN allows the company to utilize the model, including Medicare reimbursement for respite care.

GUIDE’s benefits for patients, businesses

Though the GUIDE model has only been around since July 2024, Morgenstern-Gaines and Robertson report early signs of positive impacts.

“We’re seeing that patients and families are really getting to spend more quality time together, and they’re able to enjoy the little moments together,” Morgenstern-Gaines said. “We’ve had numerous families be able to celebrate big milestones.”

Morgenstern-Gaines cited a Texas-based senior couple who were exhibiting signs of cognitive decline and struggling. The couple enrolled in GUIDE, and with access to respite care and caregiver services, they were able to attend their son’s out-of-state wedding. This example is just one of many stories that illustrate the program’s benefits, she said.

The program also helps providers beef up their referral networks, Morgenstern-Gaines said.

“A lot of our partners have been able to use GUIDE as a foot in the door to strengthen their own referral networks, so where some of our home care partners previously weren’t able to get audiences with community referral partners, they’re now able to use GUIDE as an entry point,” she said. “They’ve won over major hospital systems and memory care facilities in their local area.”  

The GUIDE Model is significant because it attempts to reach individuals and families that are most impacted by dementia, according to Robertson.

“The needs and the burdens of family members [are] very much in focus amongst health care providers and home care providers today, so this offers that support to those probably struggling the most, as a result of the effects and the progression of the dementia disease state,” he said.

The GUIDE Model engages community-based organizations that are not burdened by the administrative overhead of Medicare. Since community-based organizations, such as non-medical home care agencies that are contracting with the GUIDE participant, are not subject to Medicare conditions of participation or OASIS reporting these companies can fully focus on the delivery of care, Robertson noted.

Additionally, the model’s eight-year length allows for longitudinal, continuous care, Morgenstern-Gaines said.

“We haven’t seen other programs come out that are this dedicated to, and recognize the criticality of, the family caregiver in the support system for dementia patients,” she said. “Ensuring that family caregivers, informal caregivers, have the support, relief, guidance and confidence they need to be able to support their loved ones. It is the only way that we are going to be able to keep the 7 million plus dementia patients that we have in this country healthy at home for longer. Without that, our system will break.”

The program marks the first time that Medicare has reimbursed for ongoing activities of daily living. GUIDE provides up to $2,500 annually for respite benefits, including in-home caregivers, respite care, adult day care and more.

Looking ahead, Robertson explained that GUIDE could be a money saver for Medicare.

‘[It could] deliver savings for Medicare, as a result of fewer falls in the home, fewer emergency department visits and fewer hospitalizations, as a result of the support from GUIDE,” he said.