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:
Monthly payments to providers for dementia care coordination
On-demand, multilingual caregiver education
Access to 24/7 clinical support teams
Respite funding to give caregivers essential breaks
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 GUIDE Model was developed with three core goals:
Improve the quality of life for people living with dementia
Reduce stress and burden for family caregivers
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.
Families must meet the following criteria to qualify for services under the GUIDE Model:
Confirmed dementia diagnosis by a clinician enrolled in the GUIDE program (mild, moderate, or severe stages)
Not enrolled in hospice
Enrolled in traditional Medicare Parts A and B with Medicare as the primary payer
Not enrolled in Medicare Advantage, PACE, or Special Needs Plans
Living at home or in a community setting (not a long-term nursing home)
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.
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.
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.
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.
Families gain access to around-the-clock support through care navigation teams. This ensures caregivers are never alone in moments of uncertainty or crisis.
Depending on the provider, services may also include medication management, behavioral health screening, in-home assessments, and referrals to community-based support organizations.
Participating in or partnering with GUIDE can offer significant advantages for home care and home health agencies:
Agencies can receive per-beneficiary, per-month payments for delivering care coordination and other non-medical services under the GUIDE framework.
Even if your agency is not a GUIDE participant, you may contract with GUIDE providers to deliver respite services, home visits, or caregiver education.
Offering GUIDE-aligned services enhances your value proposition to families, referral partners, and caregivers. It positions your agency as a leader in dementia care.
Stay safely in their homes for longer
Receive personalized, coordinated care
Access services without out-of-pocket costs
Avoid unnecessary emergency room visits or hospitalizations
Learn how to manage dementia symptoms with confidence
Receive up to $2,500 in respite care annually
Reduce stress, burnout, and isolation
Access help at any time with 24/7 care team support
Get paid for services you’re already providing
Enhance training, compliance, and care quality
Build stronger relationships with families and referral networks
Improve caregiver recruitment and retention through structured education
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.
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.