Photo credit: BigStockPhoto/Ocskay Bence
by Cara Galob-Colantuono, DSW, LSW
For more than 50 years, Medicare has neglected to provide essential coverage for individuals affected by Alzheimer’s disease and other forms of dementia (Livingston et al., 2024). Social workers have long supported caregivers and patients dealing with this chronic illness as care coordinators, healthcare navigators, discharge planners, and emotional support companions. As changes occur within Medicare, there will likely be an increased demand for social workers, especially as more Americans are diagnosed with Alzheimer’s disease and other forms of dementia.
On July 1, 2024, the Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model. This innovative initiative aims to transform dementia care in the United States by applying evidence-based practices and collaborations with healthcare organizations and the Alzheimer’s Association (Zichry et al., 2025). The voluntary program will tackle the critical challenges faced by individuals with dementia and their families by offering a comprehensive and coordinated support system.
The GUIDE Model is structured to address the complexities of dementia by promoting integrated care approaches that foster better communication among healthcare providers, caregivers, and families (Ramesh et al., 2024). Acknowledging the varied needs of individuals impacted by dementia, the program focuses on tailored care plans and resources that adjust to each patient’s specific situation.
By focusing on enhancing the quality of life and ensuring access to necessary services, the GUIDE Model aims to empower not only individuals living with dementia but also their caregivers, facilitating a more supportive environment for all involved (Zichry et al., 2025). This initiative represents a significant step forward in addressing the growing demand for effective dementia care solutions in a rapidly aging population, instilling hope and inspiration in the community.
The potential benefits of the GUIDE Model are significant and promise to bring about meaningful changes in dementia care (Yount et al, 2023). These benefits, which are expanded on in this article, include person-centered care, comprehensive support, improved quality of life, enhanced communication and coordination, a focus on equity, and potential cost savings.
Person-Centered Care
The GUIDE Model emphasizes a person-centered approach that acknowledges and respects everyone’s individual needs and preferences in dementia care. The model enhances patients'’ dignity and autonomy by promoting personalized care plans tailored to the individual'’s strengths, challenges, and aspirations.
Comprehensive Support
Unlike traditional care models, the GUIDE Model offers an extensive array of services, including:
- Care Coordination and Management: A dedicated care navigator empowers individuals and families by helping them access essential services, navigate the healthcare system effectively, and connect with vital community resources.
- Caregiver Education and Support: The GUIDE Model acknowledges the immense challenges faced by family caregivers and provides robust educational programs, training, and support to ensure they are equipped to deliver exceptional care.
- Respite Care: This critical service offers caregivers much-needed temporary relief, allowing them to tend to personal needs or take breaks. This support is vital in reducing stress and preventing caregiver burnout.
Improved Quality of Life
By coordinating services effectively, the GUIDE Model aims to improve significantly the quality of life for individuals with dementia and their caregivers. Anticipated outcomes include:
- Increased Ability to Remain at Home: The model enables individuals to stay in their familiar surroundings longer by offering support and education, effectively delaying or avoiding the need for institutional care.
- Reduced Caregiver Burden: Access to respite care, education, and ongoing support alleviates caregiver stress and promotes better emotional well-being.
Enhanced Communication and Coordination
The care navigator role is pivotal in fostering improved communication among healthcare providers, caregivers, and community organizations. This enhanced communication leads to more integrated and effective care delivery, a key feature of the GUIDE Model.
Focus on Equity
The GUIDE Model ensures equitable access to care for all individuals, irrespective of geographical location, race, or ethnicity. This focus is critical in addressing disparities in dementia care and ensuring that underserved communities receive the support they need.
Potential for Cost Savings
While the primary goal of the GUIDE Model is to enhance quality of life, it is also expected to generate significant cost savings by reducing hospitalizations, emergency room visits, and the need for long-term care. This aspect of the model provides reassurance about its economic viability, making it a win-win for all stakeholders.
This model not only recognizes but also celebrates the crucial role of social workers in addressing the psychosocial and emotional needs of individuals with dementia and their families. Their involvement leads to a significantly improved quality of life and a reduction in caregiver burden. As GUIDE emphasizes community-based care and aims to delay long-term nursing home placement, social workers will be essential in connecting individuals with dementia and their caregivers to community resources, support groups, and respite care options. The model’s focus on interdisciplinary collaboration will also enhance professional opportunities for social workers to work closely with healthcare professionals, further reinforcing their vital role in dementia care.
The GUIDE Model represents a monumental leap forward in dementia care. This innovative program focuses on person-centered practices, offers comprehensive support, and prioritizes caregiver welfare, aiming to transform the lives of countless individuals and families affected by dementia. As the model is rolled out over eight years, its impact will be rigorously evaluated, providing essential insights that will shape the future of dementia care across the United States.
Furthermore, on January 17, 2025, the Centers for Medicare & Medicaid Services (CMS) published the latest participant list on CMS.gov under the section labeled GUIDE PARTICIPANT LIST (XLSX). This comprehensive list serves as an essential resource within the healthcare sector, showcasing 390 active participants from across the United States, who appear to be a combination of for-profit and not-for-profit healthcare agencies such as major hospital systems. The initiative stems from an executive order referred to as Executive Order 14095, which seeks to enhance access to high-quality care and support for caregivers. With the new administration, it is important to note that on January 20, 2025, the President signed Executive Order 14148, titled Initial Rescissions of "Harmful" Executive Orders and Actions, which rescinded more than 30 previous executive orders. Although Executive Orders 14094 and 14096 were included in this rescission list, Executive Order 14095 was notably absent, suggesting it has bipartisan support.
References
Livingston, G., Huntley, J., Liu, K. Y., Costafreda, S. G., Selbæk, G., Alladi, S., ... & Mukadam, N. (2024). Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. The Lancet, 404(10452), 572-628.
Ramesh, T., Kadakia, K., & Moura, L. (2024). Transforming Value-Based Dementia Care—Implications for the GUIDE Model. JAMA Internal Medicine, 184(3), 237-239.
Yount, R. E. (2023). CMS Announces GUIDE-A New Dementia Care Model Designed For Participation By A Range Of Providers. Mondaq Business Briefing, NA-NA.
Zikry, H. E., Friedman, A., Dresden, S. M., & Gupta, R. (2025). Integrating Emergency Departments Into The CMS GUIDE Model For People Living With Dementia. Health Affairs Forefront.
Dr. Cara Galob-Colantuono, DSW, LSW, is dual licensed in NJ and PA. She has many years of experience working in major healthcare systems such as Main Line Health, Jefferson Health, and Virtua Health. She is considered an expert in medical social work and is the Chief Executive Consultant at Gold Standard, LLC.