CMS Announces New Payment Model for Dementia Care Management

The Centers for Medicare & Medicaid Services (CMS) unveiled the Guiding an Improved Dementia Experience (GUIDE) Model - a new, voluntary nationwide program – on July 21, 2023. According to CMS, this model aims to provide support to people living with dementia and their unpaid caregivers.

The GUIDE Model primarily focuses on dementia care management, with goals to:

  • Enhance the quality of life for individuals with dementia
  • Reduce the burden on unpaid caregivers
  • Enable those with dementia to stay in their homes and communities

CMS is currently accepting non-binding letters of interest for the GUIDE Model until September 15, 2023, and plans to release a GUIDE Request for Applications (RFA) in fall 2023. The model is scheduled to launch on July 1, 2024, and will run for eight years.

New payment models from CMS can provide an opportunity to obtain financial resources that support your transition to value-based care. Explore details about the GUIDE model below.

Background

Dementia affects more than 6.7 million Americans in 2023, with projections indicating that this number will grow to 14 million by 2060. People with dementia often have multiple chronic conditions, leading to fragmented care and high rates of hospitalization and emergency department visits.

CMS developed the GUIDE Model in response to Executive Order 14095, issued in April 2023, which emphasized increasing access to high-quality care and supporting caregivers. The model also aligns with the National Plan to Address Alzheimer's Disease, promoting federal actions to improve dementia care and advance research efforts.

Purpose and Approach

The model aims to reduce disparities in access to dementia care services and enhance health equity for underserved communities. The model addresses the poor outcomes experienced by people with dementia, including hospitalization and post-acute care utilization.

The GUIDE Model will test payments for comprehensive care coordination, care management, caregiver education, support services, and respite care.

Participants will provide a standard approach to care, including a 24/7 support line and caregiver training, to allow people with dementia to remain safely in their homes. Unpaid caregivers will be connected to evidence-based education and support, as well as respite services to alleviate stress and improve their overall health. Participants will address unpaid caregivers’ needs and screen beneficiaries for health-related social needs.

Model Design

Participants in the GUIDE Model will establish dementia care programs (DCP) with interdisciplinary care teams to deliver ongoing, coordinated support to people with dementia. The care team must include a care navigator who has received required training in dementia assessment and care planning, as well as a clinician meeting one of these criteria:

  • Dementia proficiency as recognized by experience caring for adults with cognitive impairment;
  • Experience caring for patients 65 years or older; or
  • Specialty designation in neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology.

The GUIDE Model’s intended beneficiary population is community-dwelling Medicare fee-for-service (FFS) beneficiaries, including those dually eligible for Medicare and Medicaid, who meet the following criteria:

  • Beneficiary has a diagnosis of dementia, as confirmed by clinician attestation
  • Have Medicare as their primary payer
  • Enrolled in Medicare Parts A and B (not enrolled in Medicare Advantage, including Special Needs Plans and PACE)
  • Not enrolled in Medicare hospice benefit
  • Not residing in a long-term nursing home.

The model offers separate tracks for new and established programs with a focus on recruitment of diverse beneficiaries.

The model will define a standardized approach to dementia care delivery and provide an alternative payment methodology to support collaborative care.

Details will be included in the RFA to be released later this fall.

Payment Enhancement

The newly created Dementia Care Management Payment (DCMP) is paid monthly. Payments depend on whether the patient is a new or an established beneficiary, as well as the complexity of the individual. These monthly payments will range from $65 to $390 per individual.

Annual adjustments to the DCMP will be made by CMS. The adjustments will range from positive 10% to negative 3.5% depending on how participants perform on the model’s performance metrics. The metrics fall into two categories, the Health Equity Adjustment (HEA) and the Performance Based Adjustment (PBA). The HEA is designed to adjust for resource gaps in serving historically disadvantaged communities, while the PBA is designed to measure the previous years’ performance on clinical, cost, and outcomes metrics.

An additional lump-sum payment for organizations classified as “Safety Net Providers” may be awarded to help cover the up-front costs of establishing a new dementia care program. Provider status will be determined based on the percent of Medicare Part D Low Income Subsidy or dually-eligible for Medicare and Medicaid patients in a provider’s population. The amount and timing of this initial lump-sum payment will be determined at a later date.

Lastly, an annual payment of up to $2,500 per individual will be provided to offset respite care costs. Programs with at-home delivery models are required to offer respite care to patients with a caregiver and moderate to severe dementia. Non-Medicare enrolled contractors may be utilized to fulfill the respite care requirement.

Health Equity Strategy

The model emphasizes delivering equitable care and addressing health disparities in dementia, particularly for underserved communities.

CMS actively seeks participation from eligible organizations that provide care to underserved communities. Financial and technical support will be provided to safety-net providers to improve their care delivery capabilities and encourage participation in the model.

Annual reporting on progress towards health equity objectives and strategies will be required from participants. Data from the model will be used to identify disparities and target improvement activities, with a health equity adjustment to the monthly care management payment.

We’re Here to Help

To learn more about the GUIDE Model or evaluate if the model would fit within your organization’s overall value-based care strategy, please contact your Moss Adams professional.

Additional Resources

Special thanks to Jerry Wei and Jake Marshall, health care consultants, for their contributions to this article.

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