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Guide Model

We believe in providing dementia care that respects your individual goals, preferences, and needs. Our approach considers all aspects of your health journey, including physical, mental, emotional, and social health.

What is GUIDE?

The GUIDE Program is an innovative approach to dementia care developed by the Centers for Medicare and Medicaid Services (CMS) focused on improving the lives of people with dementia and their caregivers.

Eligibility

  • Diagnosed with dementia by a health care provider
  • Has traditional Medicare Parts A and B as their primary payor
  • Is not enrolled in hospice care
  • Is not a long-term nursing home resident

Disclaimer: GUIDE is a traditional Medicare Parts A and B benefit. Individuals with Medicare Advantage cannot take part in this program. However, there are other resources at our brain health clinic that they are eligible for. 

Our Services

Comprehensive Assessments

Reviews of your health and well-being including medical evaluations, cognitive testing, and support. Home safety assessment via home visit or telehealth appointment.

Care Planning and Coordination

Patient-centered personalized care plans created in collaboration with your care team.

Support and Access

Round-the-clock access to a member of your care team.

Medication Management

Regular reviews to ensure safe and effective use of medication.

Respite Care

Respite care for caregiver relief.

Caregiver Support and Education

Skill training, support groups, one-on-one assistance, and resources through our Flourishing Embrace app.

What to Expect

Current brain health patients who qualify can easily transition to the GUIDE model. Your care navigator will walk you through the process.

New patients will be scheduled with one of our providers to determine eligibility. A care navigator will call you prior to the appointment to explain the details of the program and address your questions.

Once approved for GUIDE, your care navigator will work with the medical team to:

  • Develop a specialized care plan
  • Schedule a home visit
  • Connect your family with respite services according to your needs

The Interdisciplinary Team

  • Geriatricians
  • APRNs
  • Nurses
  • Neuropsychologist
  • Social Workers
  • Care Navigators
  • Chaplain

 

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