CMS Unveils Dementia-Focused Payment Model with Interdisciplinary Care Approach

The U.S. Centers for Medicare & Medicaid Services (CMS) has unveiled a new payment model demonstration geared toward dementia-related illnesses, which are becoming more prevalent among hospice patients.

The Guiding an Improved Dementia Experience (GUIDE) Model is designed to improve the quality of life for dementia patients and their caregivers by addressing behavioral health and functional needs, as well as better coordinating care and improving care transitions between community, hospital and post-acute settings.

“While we have made tremendous progress in improving care for people with dementia through the National Plan to Address Alzheimer’s Disease, people living with dementia and their caregivers too often struggle to manage their health care and connect with key supports that can allow them to remain in their homes and communities,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “Fragmented care contributes to the mental and physical health strain of caring for someone with dementia, as well as the substantial financial burden.”

Participating patients and families will also have access to a care navigator to help them access clinical and non-medical services.

Patients will be stratified into one of five tiers, based on a combination of their disease stage and caregiver status. Care intensity and payment increase by tier, according to CMS.

Reimbursement through the model includes a per-member, per-month payment, as well as an infrastructure payment for some safety net providers. Participating operators may also receive payment for respite care.

Patients who have elected the Medicare Hospice Benefit are not eligible for the program. However, hospice and palliative care providers that offer upstream services may be uniquely suited to implement such a model, either directly or through a partnership.

GUIDE involves a trained interdisciplinary care team that delivers a standardized set of services based on a person-centered care plan, according to CMS.

“This could be a way for the tenants of palliative care to be spread more across additional beneficiaries, just given that palliative care also has this kind of advanced care planning and thoughtful approach of including caregivers,” Tina Hansen Pickett, managing director at the consulting firm ATI Advisory, told Hospice News. “So there could be some collaboration there.” 

Health care providers, including hospices, can expect an influx of patients with dementia-related conditions in the coming years

Nearly 6.7 million seniors in the United States have been diagnosed with Alzheimer’s or other dementias, according to a 2023 report from the Alzheimer’s Association. By 2050, this is expected to nearly double to 12.7 million people.

Patients with these conditions represented the largest proportion of hospice patients by principal diagnoses in both 2019 (20.1%) and 2020 (18.5%), according to the National Hospice and Palliative Care Organization (NHPCO). The second-most prevalent diagnoses in 2020 were circulatory and heart conditions at 9.3%, followed by cancer at 7.5%, NHPCO reported.

Stakeholders in the provider space applauded the model.

“Nonprofit, mission-driven aging service providers know that caring for an older adult with dementia is complex—and that family and friends are a critical part of the care team,” Katie Smith Sloan, president and CEO, LeadingAge,” said in a statement. “Many of our provider members already dedicate time and resources to educating unpaid caregivers, and need alternative payment models like the one announced today to support those efforts and help keep people in the setting of their choice.”

Consistent with the Center for Medicare and Medicaid Innovation’s (CMMI) stated goal of advancing health equity, the model contains provisions designed to foster utilization among underserved communities.

“We know that Black, Hispanic, and Asian Americans, Native Hawaiian, and Pacific Islander populations have been particularly disadvantaged in receiving dementia care,” Brooks-LaSure said. “The GUIDE Model will provide new resources and greater access to specialty dementia care in underserved populations and communities.”

CMS will release the application for GUIDE in Fall 2023. The agency “encourages” providers to submit Letters of Intent to CMS by Sept. 15. The eight-year demonstration model will begin July 1, 2024.

“It’s building from prior evidence-based dementia care models. There’s a number of models that have been tested in detail and evaluated about the effectiveness of providing really coordinated interdisciplinary care for dementia patients and then their caregivers,” Picket said. “That includes detailed, person-centered dementia care plans, generally include some sort of care coordinator,, and then also an ability for the caregivers to really reach out and work with the dementia care teams whenever needed.”