CMS GUIDE model explained: How it supports coordinated dementia care and caregivers

Dementia care in the U.S. has long been fragmented, leaving many patients and caregivers to navigate complex medical, social and community needs with limited coordination. As the number of people living with dementia continues to grow, so does the strain on families and the health care system. To address these challenges, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improved Dementia Experience (GUIDE) Model, a national initiative designed to evaluate and advance higher levels of dementia care coordination.

The GUIDE model examines whether providing comprehensive, coordinated services improves outcomes for people living with dementia and their caregivers while reducing avoidable health care utilization. 

What the GUIDE model aims to address

Dementia prevalence continues to rise, and many individuals lack access to consistent, high-quality coordinated care. Nearly 42% of Americans over age 55 are projected to develop dementia, and the number of cases is expected to double by 2060 — contributing to higher rates of hospitalization, emergency department visits and caregiver strain. These trends place significant demands on families and caregivers and highlight gaps in dementia care coordination:

• About 80% of adults with dementia receive care in their homes (CDC).
• Approximately one in three caregivers for people with Alzheimer’s disease or other dementias are 65 or older (CDC).
• Nearly 12 million caregivers provided an estimated 19 billion hours of unpaid care to people with Alzheimer’s disease in 2024 (Alzheimer’s Association).

“Care for people with dementia has historically been fragmented,” said Kari Anderson, MS OTR/L, Enhabit’s director of community services. “Patients often see multiple providers, and without coordination, caregivers are left feeling unsure where to turn or how to access the support they need.”

“Until now, there hasn’t been a Medicare model that explicitly includes both the person with dementia and their caregivers in the care plan,” Anderson said.

Why coordinated dementia care matters

Research shows that well-coordinated, interdisciplinary dementia care can significantly improve outcomes. A 2020 study published in the Journal of the American Geriatrics Society found that structured dementia care programs were associated with 20% fewer emergency department visits and 26% shorter hospital stays.

Beyond clinical outcomes, coordinated care supports patients’ ability to remain at home. A study in JAMA Internal Medicine reported a 40% lower risk of long-term nursing home placement and more timely hospice use when dementia care was delivered through structured care models.

Since 71% of Americans say they would prefer to spend their final days at home, coordinated dementia care helps align clinical support with patient preferences while easing caregiver burden.

What the GUIDE model is

The GUIDE model provides Medicare coverage for a comprehensive package of dementia care coordination and care management services, along with education and respite support for qualifying caregivers. 

This eight‑year CMS initiative is designed to establish a more sustainable, connected dementia care pathway. Its goals include:

• Helping people with dementia remain safely at home longer
• Reducing hospitalizations, emergency department use, and post-acute care utilization
• Supporting unpaid caregivers through access to education, training and respite services
• Improving quality of life through interdisciplinary, person-centered care
• Strengthening coordination among health care providers and community-based organizations

How the GUIDE model addresses care gaps

The GUIDE model establishes standardized expectations for dementia care delivery, requiring participating organizations to provide: 

• Interdisciplinary care teams: Clinicians with dementia experience, care navigators, and direct care staff deliver coordinated, person-centered care.
• Care navigation: Assigned care navigators help patients and caregivers access clinical services and community-based resources.
• 24/7 access: Around-the-clock support lines address urgent questions and concerns.
• Caregiver support: Education,training and connections to community resources are tailored to caregiver needs as they evolve.
• Health-related social needs screening: Participants assess psychosocial and social needs and connect families with local organizations for support with challenges such as meals and transportation.

How GUIDE payment is structured

The CMS GUIDE model uses a value‑based payment approach that includes tiered monthly care management fees, performance-based incentives, caregiver respite funding and one‑time infrastructure payments for safety‑net providers.

Eligibility includes individuals with diagnosed or suspected dementia who:

• Have Medicare Parts A and B
• Live in a community setting
• Are not enrolled in hospice or residing in a long‑term care facility

Key payment components include:

• Monthly dementia care management payments: Tiered per-patient payments adjusted based on patient complexity, caregiver burden and performance on quality measures.
• Respite services payments: Up to $2,500 annually per eligible patient to support temporary caregiver relief through in-home care, adult day center programs or facility-based respite.

The GUIDE model also emphasizes equity by supporting people who are dually eligible for Medicare and Medicaid through: 

• Financial and technical assistance for underserved and rural communities
• Data-driven quality improvement strategies
• Infrastructure funding for safety-net providers   

How GUIDE complements Enhabit’s Dementia Care Program

Because GUIDE eligibility and respite benefits are limited, Enhabit clinicians help patients, families and caregivers understand whether the model may apply to them and how to access available community resources.

“Our role at Enhabit isn’t to deliver the GUIDE program,” Anderson said. “It’s to make sure patients and families are aware of it and understand how available resources can best support them.”

Through an age-friendly approach to care — centered on what matters most to each patient — Enhabit helps bridge the gap between clinical care and daily life. Enhabit’s Dementia Care Program supports this approach through ongoing assessment of cognition, behavior, functional decline and safety risks, and equips caregivers with practical guidance on mobility, communication, daily routines and symptom management. By identifying changes early, clinicians can help families stabilize daily life and connect them to additional support, including GUIDE services, when appropriate.

By helping families navigate complex benefits and resources, coordinated care supports a more stable dementia journey — one focused on guiding an improved dementia experience for patients, families and caregivers.