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The CMS GUIDE Model and Cognitive Testing

The GUIDE Model, a program of the CMS Innovation Center, is creating a promising new path for dementia care and caregiver support.


In summer 2023, Centers for Medicare Services (CMS) announced the GUIDE Model, a new voluntary care delivery model to support individuals with dementia and their unpaid caregivers. At that time, they began accepting applications from partner organizations in all 50 states and US territories with a plan to launch in summer 2024. As a maker of digital cognitive tests, an important component in identifying dementia, Neurotrack applauds this effort and will support both GUIDE Model participants and referring physicians. 

Table of contents

What is the GUIDE Model? 

GUIDE is an acronym for Guiding an Improved Dementia Experience. 

The GUIDE Model helps set up and support a new wave of dementia care programs. These innovative programs will improve upon current care models by employing interdisciplinary teams to deliver standardized services, longitudinal care, and ongoing support to people with dementia and their caregivers.

Why is the GUIDE Model needed?

Dementia, long considered an inevitable result of aging, hasn’t been a priority of our healthcare system until recently. With our Baby Boomers aging, the US is about to experience a wave of new cases, and this program is a concerted effort by CMS to proactively address anticipated gaps in care and avert a crisis.

According to the 2024 Alzheimer’s Association Facts & Figures report, 60% of healthcare professionals concede that the US healthcare system isn’t doing enough to help patients and families navigate dementia care. 

In previous Alzheimer’s Association surveys, 40% of primary care providers say they’re uncomfortable making a dementia diagnosis and 50% say they’re not prepared to handle care for Alzheimer’s disease. 

We also know that most dementia caregivers are unpaid family members with no breaks or respite available. And nursing assistants in care homes have some of the highest rates of turnover, as high as 99%. 

Fragmented care by reluctant providers and overburdened caregivers leads to poor outcomes and skyrocketing costs, including high rates of hospitalization, emergency department visits, and post-acute care utilization. 

What will the GUIDE Model accomplish?

The aims of the GUIDE Model program are simple: 

  • Improve quality of life for dementia patients
  • Reduce burden on caregivers
  • Help individuals remain in their homes as long as possible

Well-coordinated dementia care leads to better outcomes, improves health equity, reduces hospitalizations and mental health issues for patients and their families, lowers costs, and significantly reduces burden on caregivers. 

Are there any restrictions on which patients can participate in GUIDE?

Yes, this program is designed for Medicare fee-for-service (Parts A & B) beneficiaries, diagnosed with dementia, who are not yet living in long term care or receiving a Medicare hospice benefit. Medicare Advantage (MA) customers will not be eligible.

What are the key components of the GUIDE Model?

Care coordinators: This team member will help beneficiaries access community services, answer questions about dementia care, and serve as a go-to resource for patients and families.

Clinicians with dementia proficiency: The clinicians involved with GUIDE will have experience caring for cognitively impaired adults, patients 65+, or qualifications in the fields of neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology.

Person-centered care plans: Created by an interdisciplinary care team, this plan should address the patient's goals, strengths, and needs, the results of the comprehensive assessment, and recommended services and support.

Caregiver services: Caregivers will gain access to 24/7 hotlines to address concerns or answer questions. They'll also have access to specialized training programs to learn best practices of dementia care, as well as respite services, so they can get a much needed break.

When will the GUIDE Model program launch? 

In early April 2024, CMS announced that certain healthcare companies and care providers had been accepted as participants in this innovative program. Established programs are expected to begin to deliver care in July 2024. New programs will have a year-long “pre-implementation period” beginning in July 2024 to give them time to set up their infrastructure. CMS will make a directory of all GUIDE providers available to the public in Summer 2024. (When this directory is live, we will add a link to it here.)

How can Neurotrack support GUIDE Model providers?

Neurotrack can help design a seamless referral system from primary care to GUIDE Model care teams.

Neurotrack is a leader in digital cognitive testing, the first step in a dementia diagnosis. Conducting a brief cognitive screen in yearly checkups is an effective way to identify those who may be at risk for dementia. Our objective, first-line cognitive screening test can detect cognitive impairment in 3 minutes in brick and mortar or virtual settings.

If the patient scores low, the PCP can administer Neurotrack’s secondary tests and conduct further investigation. Once a dementia diagnosis is made, the patient can be referred to a GUIDE provider.

And there are other ways that GUIDE providers and PCPs can assist each other prior to the diagnosis step. Get in touch to learn more about these strategies. 

After diagnosis, GUIDE Model care coordinators will do what they do best. They'll conduct staging, create a care plan, and match the caregiver with appropriate support.

What if my team has no bandwidth for the volume of patients who might need a diagnosis? 

We can share some helpful new strategies to support backlogged physicians so that no one misses out on this innovative program. Reach out to us for more details.

How does Neurotrack support PCPs and other providers who want to refer patients into the GUIDE Model?

Our digital cognitive tests make it easy to screen for cognitive impairment routinely in annual wellness visits or other visits. Our patient-guided tests enable teams to work at the top of their license. 

  • They can be overseen by MAs during the rooming phase of an in-clinic visit.
  • They can be taken at home on any device prior to the visit.
  • They also work in house call or telehealth settings.

A low score on Neurotrack’s screening can identify the patients in your population that may be eligible for diagnosis and referral to GUIDE Model providers.

Can any physician participate, even if they haven't applied to the GUIDE program?

Yes, any doctor can refer qualified patients to GUIDE Model participants.  Medicare fee-for-service beneficiaries can also locate and contact participating GUIDE Model providers on their own.