Senior living operators hoped the GUIDE model would help them support caregivers. So far, the program hasn’t gone as well as some had wished.
CMS launched the Guiding an Improved Dementia Experience (GUIDE) model last year as an eight-year nationwide program to provide better services and support for people living with dementia and their caregivers. The program aims to offer comprehensive support services, including care navigation, access to respite care, caregiver education and 24-hour support for caregivers. The model provides wraparound services for people caring for dementia patients, such as in an older adult’s home or in a senior living unit.
Senior living operators such as United Church Homes (UCH) previously sought to use the GUIDE program to improve care navigation efforts, receive reimbursement for respite care services and create more education and awareness of dementia and cognitive decline.
But since starting the program senior living providers have run into challenges related to eligibility, referral pathways, respite operations and broader implementation.
The first year of GUIDE has forced operators to redesign intake, documentation and approval processes, which can often move at a slow pace despite the urgent need to provide services to a family caregiver. Exacerbating the issue is that senior living operators started the GUIDE program with different levels of readiness, and some operators felt as though they started the race behind their peers.
“The highs are when we first bring people on and we see the successes, but we’re not all on the same playing field,” said United Church Homes Senior Executive Director Amy Kotterman.
Eligibility, payer mix, staffing pose operational challenges
Senior living operators enrolled in the GUIDE program have run into challenges around identifying eligible beneficiaries and scaling enrollment when many residents are on Medicare Advantage rather than traditional Medicare. Compared to senior living providers, medical practices can ramp faster because they can look at past diagnosis and medical histories more quickly and have access to insurance records that can clearly show whether or not a patient meets GUIDE eligibility.
For one, dementia care practitioners in GUIDE interact with more older adults than a physician or health system group normally would with patient lists in the thousands. For operators without that scale, Kotterman said the first year became an outreach-and-referral problem as much as a care navigation challenge.
This led to senior living providers needing to rethink their outreach and referral strategies to enroll eligible residents into the GUIDE program, making education a top priority for providers as they seek to reach more families caring for a loved one with dementia at home.
Episcopal SeniorLife Communities cut its teeth in GUIDE this year and brought in third-party companies to improve its initial rollout, according to Vice President of Dementia Program Development Teresa Galbier at Episcopal SeniorLife Communities.
To close early operational gaps around respite execution and speed, some organizations opted to partner with third-party groups rather than create in-house capabilities for training, education and outreach. In Galbier’s experience, timelines for respite care approvals “could take months,” creating friction “once families were ready,” before services could be arranged for family caregiver respite.
Early on, senior living providers adopted GUIDE expecting strong internal uptake, then ran into payer and setting constraints that reshaped initial plans for hitting key events in an organization’s rollout of GUIDE, Kotterman noted. The GUIDE model requires participants in traditional Medicare plans and the complex mix of plans used by senior living residents diminished the pool of eligible participants able to participate in the program.
UCH initially expected more qualifying residents in independent living and assisted living settings to participate in GUIDE, and this issue was shared by other providers. With fewer than anticipated qualified residents, this lack of scale presents challenges for operators seeking to expand the reach of services incorporated to the GUIDE program.
“I thought we would have a larger pool of candidates and that necessarily hasn’t been the case,” Kotterman said.
Approximately 60% of residents were using Medicare Advantage plans and 40% were still using traditional Medicare Parts A and B plans. The GUIDE model requires traditional Medicare Parts A and B as the primary payer source for the services, and Episcopal SeniorLife communities had fewer than 20% of residents on those types of health plans, Galbier said. That has only complicated enrollment for operators, Kotterman noted.
CMS rates for respite care also are lower than market rates, which can make contracting for respite care services as part of a GUIDE case a challenge.
The rollout of GUIDE is also changing the narrative, as senior living providers now have to educate families on an unfamiliar model in dementia care that many families still struggle to discuss openly due to the social implications of dementia itself, providers told SHN.
Episcopal SeniorLife realized early on that “communications and marketing must be airtight,” and some GUIDE messaging “caused confusion” among prospective residents early on.
UCH care navigators encounter reluctance from families with a loved one living with dementia, or family caregivers who minimize or deflect an older adult’s eligibility for aspects of the GUIDE program.
“There is still such a stigma around dementia and Alzheimer’s disease that really has impacted the entire process of outreach,” Kotterman said.
Early education plays an important role in getting folks acclimatized to GUIDE, and EverTrue uses an assessment known as the Zarit Caregiver Burden Index at the time a GUIDE case is opened with each family caregiver to measure stress. EverTrue will complete the assessment again when a GUIDE case reaches 12 months.
GUIDE supports the family caregiver, not the staff caregiver, which is an important distinction, according to At Home Harmony CEO Will Saunders, because education on GUIDE has been limited in the first year. The At Home Harmony platform includes in-home technology and pharmacy services in a medical practice to help older adults stay at home longer.
Saunders said medical practices, with deep rosters of patients, are “best positioned” to introduce GUIDE, given their scale of resources and patients potentially eligible for the program.
Even finding health practices with knowledge of GUIDE early on was a challenge, Kotterman said, noting that “hardly anyone” was aware of the program’s existence or ways to use the program for their roster of patients on traditional Medicare plans who could be eligible for GUIDE services.
Senior living operators implementing GUIDE in some cases also underestimated the level of staffing that care navigation required. Episcopal SeniorLife used a “care ecosystem toolkit” and added additional training and professional development to familiarize staff with GUIDE expectations. The toolkit came from the University of California San Francisco (UCSF) that provides implementation and planning materials, along with clinical protocols, from the UCSF Memory and Aging Center to spur an organization’s rollout of an evidence-based dementia care navigation program, delivered through phone and online services for an older adult living with dementia and their family caregiver.
EverTrue Anywhere Care made dementia training and competency universal across its organization, with all staff required to complete a four-hour dementia-specific training program, according to EverTrue Anywhere Care Vice President Colleen Bottens. EverTrue Anywhere Care aims to provide services to help older adults age in place in their homes or reach residents at EverTrue communities with GUIDE services.
As EverTrue started its year-one rollout, leaders realized that demand for care navigation services was most immediate in their life plan communities where residents were caring for spouses with dementia. This led the organization to “narrow our focus,” Bottens said, and focus on dementia care navigation. Other challenges included delays for approval of GUIDE cases by CMS. Another challenge to overcome is CMS reimbursement rates for respite care being lower than market rates, making it difficult to find third-party organizations to partner with to offer caregiver relief services, a crucial piece of the GUIDE model.
EverTrue found that family caregivers were looking for on-demand educational resources. EverTrue partnered with an online platform to create an on-demand platform for GUIDE family caregivers, something that is now a “valuable tool” for educating caregivers and older adults in the GUIDE program.
These types of partnerships are “essential,” Galbier said, to find clinical partners and establish respite care provider relationships.
In the first year, five GUIDE providers in the Saint Louis area have formed “a collaborative” to meet quarterly to talk through challenges and share best practices, Bottens said.
“Like with any new program, workflow has been a learning experience. Initially there was a lag between assessing the client for GUIDE and getting CMS approval for “alignment”; however, we now have a way to get real-time approval,” Bottens said. “Things are improving all the time.”
