CMS GUIDE Program Services
CMS GUIDE Program
The GIA and the GRILL Lab introduces the Centers for Medicare & Medicaid Services (CMS) GUIDE Program. These services are similar to the GIA Personalizable Treatment Plan.
CMS GUIDE Services
Comprehensive Assessment
Persons with Dementia and their family members receive separate assessments to identify
their needs and a home visit to assess the beneficiary's safety.
Care Plan
Persons with Dementia receive care plans that address their goals, preferences, and
needs, which helps them feel certain about next steps.
24/7 Access
Persons with Dementia and their family members can call a member of their care team
or a third-party representative using a 24/7 helpline.
Ongoing Support
Care navigators provide long-term help to persons with Dementia and their family members
so they can revisit their goals and needs at any time and are not left alone in the
process.
Referral Coordination
Persons with Dementia and their family members will be connected to community-based
services and supports, such as home-delivered meals and transportation.
Caregiver Support
Family members can take monthly educational classes that address common questions
and behavioral management, which helps relieve the challenges of caregiving duties.
Medication Management
Clinician reviews and reconciles medication as needed, through care navigators who
provide tips for persons with Dementia to maintain the correct medication schedule.
Care Coordination & Transition
Persons with Dementia receive timely referrals to specialists to address other health
issues, such as diabetes, and the care navigators coordinate care with the specialist.
CMS GUIDE Eligibility
Eligibility for CMS GUIDE Service is determined by:
• Dementia Diagnosis (Can be determined at first visit)
• Enrolled in Medicare A & B
• Not Residing in Long Term Nursing Home
• Not Enrolled in Medicare Hospice
• Not Enrolled in the Program of All-inclusive Care for the Elderly (PACE)