Why GUIDE Matters Now
More than 6.7 million Americans currently live with Alzheimer’s disease. That number is expected to more than double to 14 million by 2060, placing unprecedented strain on families, caregivers, and healthcare providers. Over 11 million unpaid family caregivers support these individuals today—most without formal guidance, financial assistance, or access to care coordination.
The GUIDE Model addresses this urgent need by offering:
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Monthly payments to providers for dementia care coordination
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On-demand, multilingual caregiver education
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Access to 24/7 clinical support teams
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Respite funding to give caregivers essential breaks
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Tools to help people remain safely at home, longer
For home care and home health agencies, this means the services you already provide can now be reimbursed—and delivered with greater structure, support, and clinical oversight.
The Mission Behind the GUIDE Model
The GUIDE Model was developed with three core goals:
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Improve the quality of life for people living with dementia
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Reduce stress and burden for family caregivers
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Delay or prevent institutional care by supporting home-based living
GUIDE is designed to fill critical gaps in care through proactive, coordinated services—all covered under traditional Medicare, with no out-of-pocket costs for eligible families.
Who Is Eligible for GUIDE?
Families must meet the following criteria to qualify for services under the GUIDE Model:
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Confirmed dementia diagnosis by a clinician enrolled in the GUIDE program (mild, moderate, or severe stages)
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Not enrolled in hospice
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Enrolled in traditional Medicare Parts A and B with Medicare as the primary payer
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Not enrolled in Medicare Advantage, PACE, or Special Needs Plans
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Living at home or in a community setting (not a long-term nursing home)
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Residing within the designated geographic service area of a GUIDE provider
Agencies serving these individuals can become key partners in providing GUIDE-aligned services through a GUIDE-approved entity like PocketRN.
What Services Does GUIDE Include?
Comprehensive Care Coordination
GUIDE assigns each patient an interdisciplinary care team to oversee the medical, emotional, and social aspects of their condition. This ensures consistent support, better transitions of care, and reduced fragmentation.
Caregiver Training and Support
Family caregivers receive customized, accessible training tailored to their loved one’s stage of dementia. Education is available in multiple languages and includes strategies for behavior management, communication, and safety.
Respite Services
Recognizing the demands of full-time caregiving, GUIDE includes reimbursement for up to $2,500 per year in respite care, which can be delivered at home, in adult day centers, or approved facilities.
24/7 Clinical Support
Families gain access to around-the-clock support through care navigation teams. This ensures caregivers are never alone in moments of uncertainty or crisis.
Additional Services
Depending on the provider, services may also include medication management, behavioral health screening, in-home assessments, and referrals to community-based support organizations.
Why GUIDE Matters for Your Agency
Participating in or partnering with GUIDE can offer significant advantages for home care and home health agencies:
New Revenue Streams
Agencies can receive per-beneficiary, per-month payments for delivering care coordination and other non-medical services under the GUIDE framework.
Partnership Opportunities
Even if your agency is not a GUIDE participant, you may contract with GUIDE providers to deliver respite services, home visits, or caregiver education.
Competitive Differentiation
Offering GUIDE-aligned services enhances your value proposition to families, referral partners, and caregivers. It positions your agency as a leader in dementia care.
Who Benefits from GUIDE?
Individuals Living with Dementia
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Stay safely in their homes for longer
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Receive personalized, coordinated care
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Access services without out-of-pocket costs
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Avoid unnecessary emergency room visits or hospitalizations
Family Caregivers
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Learn how to manage dementia symptoms with confidence
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Receive up to $2,500 in respite care annually
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Reduce stress, burnout, and isolation
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Access help at any time with 24/7 care team support
Home Care and Home Health Agencies
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Get paid for services you’re already providing
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Enhance training, compliance, and care quality
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Build stronger relationships with families and referral networks
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Improve caregiver recruitment and retention through structured education
Nevvon and PocketRN: Your Partners in GUIDE-Aligned Care
Two organizations are helping agencies meet GUIDE’s requirements with scalable, evidence-based tools:
PocketRN provides virtual, on-demand clinical support, connecting patients and caregivers with licensed nurses anytime they need help. This enhances the 24/7 support backbone of the GUIDE model.
Nevvon delivers caregiver training through a mobile-first platform, offering stage-based dementia education in over 14 languages. The training is designed to be accessible, engaging, all while supporting the family and family caregivers with resources they need to support the ones they love.
Together, PocketRN and Nevvon empower agencies to deliver high-quality, GUIDE-aligned dementia care—efficiently and at scale.
Final Thoughts
The GUIDE Model represents a fundamental shift in how dementia care is supported in the home. For home care and home health agencies, it brings a unique chance to lead in the next era of senior care—while strengthening your services, improving family outcomes, and receiving reimbursement for critical work you’re already doing.
Now is the time to prepare.
