Should you participate in the Innovation Center's GUIDE Model?

The GUIDE Model (Guiding and Improved Dementia Experience) broken down

Author

Dana Prommel Strauss
October 14, 2023

I use Notion and Notion AI every day to capture ideas, brainstorm, organize and link ideas, create mini-sites, do research, as a bookmark tool, write white papers, organize photos, share anything with anyone, create mini-sites, and so much more.

Notion has become my second brain.

The Guide Model is an opportunity for many new provider types to participate in a CMS Innovation Center Model: I’ll tell you why!

Part Two: How does it work and who can participate?

(You can access Part One Here)

It takes time to get a true understanding of a model from the information CMS provides. I have synthesized that for you below from the details available (more to come when the Request for Applications (RFA) is released later this fall).

The Basics:

The model is classified as a condition-specific longitudinal care model.

This model is widely available to interested participants who can meet the requirements. Overlap between GUIDE and other accountable care and Innovation Center models is permitted, even encouraged, like for beneficiaries attributed to ACO REACH and MSSP ACO entities and Participating Providers.

This model also has NO DOWNSIDE RISK.

There are two provider types that may participate in a Dementia Care Program:

  1. Participants (the Billing TIN): Medicare B enrolled providers/suppliers, excluding DME and lab suppliers, what are eligible to bill for Medicare Physician Fee Schedule Evaluation and Management codes who can meet the requirements or contract with organizations who can.

  2. Partner Organizations: Other providers and suppliers who can help the Participants meet care delivery requirements. They must be eligible to bill Medicare Part B but don’t have to have eligibility by the time of the application.

Participants must have a minimum of two team members on the “interdisciplinary care team:

  • A “Dementia Proficient Clinician”, which is defined as any ONE of the following:

    • Specialty Designation of geriatrics, neurology, psychiatry, geriatric psychiatry, behavioral neuro, or geriatric neurology or

    • At least 25% of the clinician’s patient panel are aged 65 years old or older or

    • At least 25% of the clinician’s patient panel includes adults with any cognitive impairment, including dementia

  • A care navigator:

    • CMS is NOT requiring a navigator to have specific credentials or professional accreditation

    • They must receive training specific topics related to dementia (in RFA to come)

      • Participants may create their own training or use materials available through other organization

    • Just a few examples of those that fill the role:

      • Community Health Worker

      • Social Worker

      • Registered Nurse

What types of providers can be contracted as “Partner Organizations?”

  • Home Health Agencies

  • Adult Day Care Centers

  • Assisted Living Facilities

  • Physical and Occupational Therapy Practices

  • FQHCs

  • Community Based Organizations

  • Geriatric Care Manager organizations

Each GUIDE Dementia Care Program must be able to meet the following requirements for their enrolled patients (telehealth may be used to meet many requirements):

  • Perform a Comprehensive Assessment

  • Establish a Care Plan

  • Referral support and coordination (connecting beneficiaries to community-based organizations’ supports)

  • Provide caregiver support

  • Medication management

  • Respite services (in-home capability is a program requirement, and adult day care centers, assisted living facilities, and others may provide inpatient respite and/or day respite for other respite options)

  • Care coordination and transition support, such as coordinating care with specialists who can support additional medical needs

A few examples of other types of support that may be provided through the program’s monthly payment or through coordinated referrals to other community providers who bill Medicare:

  • Home modifications

  • Home rehabilitation therapy services

  • Behavioral Health support

Beneficiary Eligibility:

  • Dementia diagnosis at any stage. Diagnosis confirmed by clinician participating in the GUIDE program

  • Have Medicare Parts A and B as primary insurance

  • Is not a nursing home resident

  • Is not enrolled in Medicare Hospice

  • Is not enrolled in PACE

Note that beneficiaries in assisted living facilities are eligible for alignment to a GUIDE Dementia Care Program

A beneficiary becomes part of the program through voluntary alignment. The GUIDE participant. What does this mean?

The Participant informs beneficiaries about the model and its services available, and they document that the beneficiary or their legal representative consents. 

This is MUCH easier than traditional voluntary alignment that we see in CMS ACO Models.

Payment Methodology:

Dementia Care Management Payment for collaborative care and caregiver education and support. Covers care delivery services, paid monthly

  • Replaces physician fee schedule billing for certain care management services

  • Amount varies based on patient’s dementia stage, caregiver presence, and a few other factors

Adjustments to DCMP

  • Performance-Based Adjustment (PBA), a percentage based on how participants perform on various metrics

  • Health Equity Adjustment (HEA) based on beneficiary-level health equity scores

Payment for Respite Services

  • For those with moderate to severe dementia and an unpaid caregiver, the participant is able to bill Medicare for respite services of up to $2500 per year

In Addition

Safety net providers (participants with a threshold number of dual eligible beneficiaries and/or those with low-income subsidy) will receive $75,000 as an up-front infrastructure payment in July 2024 to establish their Dementia Care Program

Want my perspectives on what some successful Participants could look like?

  1. Provider TINs that care for beneficiaries when they access urgent and/or inpatient services for behavioral health exacerbations

  2. Provider TINs who care for beneficiaries living in assisted living facilities, continuing care retirement communities, and/or independent living facilities (who may or may not have an unpaid caregiver living with them)

  3. Specialists in one of the listed provider specialty types, particularly multi-specialty geriatric practices

  4. Primary care or multi-specialty provider practices who only care for seniors (including those participating in other value-based care models)

  5. Home Health Agencies that have or create a Medicare B Billing TIN and secure NPI-level participation for being clinical leaders for the program

  6. MSSP ACO Participants

  7. Innovation Center model Participants, including but not limited to Primary Care First, ACO REACH, BPCI-A

  8. Providers who can enroll beneficiaries through referrals from adult day-care centers

  9. Providers serving or willing to serve beneficiaries in safety net communities

  10. PACE programs and Hospices utilizing a separate Medicare Part B TIN

  11. Organizations who work closely with the Alzheimer’s Association

  12. Home-based care providers, including home-based care physician groups like primary care and palliative care practices

Partner Organizations and Other Organizations Have Many Options:

There are many ways to support Participants through Partner Organization agreements, providing additional medically-necessary services, or both.

If you are potential Partner Organization, consider reaching out to potential Participants about collaborating on the model

Examples:

Rehabilitation Therapists who see patients in their homes (especially PT/OT) could provide support through the DCMP (example: home safety and modifications, caregiver training) and/or through the physician fee schedule (traditional therapy services including, if finalized in the 2024 Physician Fee Schedule Proposed Rule, caregiver training services (new g-code, hopefully finalized in the 2024 Physician Fee Schedule Final Rule)

Home Health Agencies can participate in ways such as through a new Medicare Part B TIN, providing in-home respite services

Assisted Living Facilities and CCRCs can contract with the Participant TIN(s) who see qualifying beneficiaries at their facilities, serving as an inpatient respite option

Geriatric Care Managers can provide services for caregiver support, personal care navigation, training navigators in dementia care, and more

Thanks for reading!

All the best,

Dana