The Guiding an Improved Dementia Experience (GUIDE) payment model could have a ripple effect on hospice reimbursement.

The eight-year value-based care payment demonstration has seen widening participation among several hospice and palliative care providers nationwide. Participants in the capitation payment model receive a fixed monthly payment for each patient, regardless of the specific services they provide.

The GUIDE model’s emphasis on collaborative care, caregiver support and respite could result in greater potential for hospices to provide services that fall outside of Medicare fee-for-service reimbursement, said Amy Etzel, manager of ancillary services at The Connecticut Hospice. Eztel oversees the hospice’s palliative care services and its dementia program.

“GUIDE is really the first model to say out loud that family caregivers are the care team,” Etzel told Hospice News. “This is a truly revolutionary program [and] has been long overdue in really filling that gap of unpaid caregiver burden. It fills a gap that traditional fee-for-service structures have never addressed. It could be applied to other [patients] outside of dementia populations. The emphasis on care navigation, caregiving training and respite is really groundbreaking.”

Building the infrastructure

The GUIDE model creates pathways for hospices to engage earlier with patients and their families, Etzel indicated. Through the payment model, hospices can reach patients upstream and develop stronger referral relationships. The GUIDE model has the potential to help hospices ensure smoother transitions of care and expands opportunities for more meaningful end-of-life experiences, she indicated.

Roughly 85% of patients discharged from The Connecticut Hospice’s dementia program transition to hospice services when eligible. Many of its GUIDE referrals also enroll in the hospice’s palliative care program, according to Etzel.

The Connecticut Hospice is joined by several other hospice and palliative care providers participating in the GUIDE model. These include Alivia Care Solutions, Avow Care Services, Delaware Hospice Inc., Hospice of the Chesapeake, Empath Health, Gilchrist Hospice Care and Andwell Health Partners, among others. CMS’ recently published a GUIDE map showed that participating organizations are predominantly located in Midwestern and Eastern regions.

The GUIDE model is essentially a building inroads for palliative care payment among dementia patient populations, according to Edo Banach, strategic advisor at the law firm Manatt, Phelps & Phillips LLP. The payment demonstration covers a range of nonmedical services alongside caregivers support and training, a model that could potentially be expanded across other diagnoses and conditions, he stated.

Hospices should be carefully watching how the GUIDE model unfolds to gauge its impacts on other reimbursement avenues beyond their traditional fee-for-service landscape, Banach indicated. Hospice providers’ greatest leverage in future payment models is demonstrating the value proposition of their services to reduce health care costs and improve outcomes, he said.

“Think of GUIDE as a peek into the future of Medicare reimbursement. The sky is the limit,” Banach told Hospice News. “If this works, then it turns out that providing more care — albeit different care — can save Medicare money while improving quality of care. This could be transformational for Medicare fee-for-service and for any value-based or Medicare Advantage model that is required to provide care that is at least as generous as FFS.”

Hospices have significant potential to help alleviate some of the most pressing challenges experienced by patients and their families, particularly for those nearing the end stages of dementia, according to Dr. Adam Flowers, CEO and medical director of Vesper Medical Care and oversees its GUIDE program. Flowers is also medical director of Bluebonnet Health Services’ hospice program. The Texas-based health system also provides home health, supportive care and bereavement services. Flowers oversees the hospice’s GUIDE program for Vesper Medical Care.

Vesper is part of a seven-member GUIDE coalition that has convened to share and disseminate best practices in care delivery. The coalition is a mix of Medicare health care providers and tech-enabled entities including the Texas-based health system Ceresti Health, Craniomatrix, Harmonic Health, Isaac Health, Pocket RN and Tembo Health.

Many of the most “unpleasant manifestations” of dementia conditions become more difficult to deal with during the end stages of the disease, Flowers stated. The GUIDE model allows families improved avenues to connect with a high-quality hospice experienced in managing a multitude of symptoms and needs, he said.

“The GUIDE program will revolutionize the way people in this nation experience dementia,” Flowers told Hospice News in an email. “They will stay at home longer with lower personal stress and lower caregiver burden through community support, a connected provider team, respite services and crisis management. It also serves as an excellent pathway towards hospice, as the conversations about future expectations start early with a realistic understanding of the terminal nature of dementia and warning signs that [about when someone] is entering its end stages.”

Through the GUIDE model, hospices have the potential to help reduce high-cost emergency services and improve patient and family satisfaction, said Jenna Morgenstern-Gaines, co-founder and CEO of PocketRN.

Launched in 2021, PocketRN last year piloted a dedicated dementia program designed to test the different components of the GUIDE demonstration. The dementia program has resulted in “significant” Medicare cost savings by up to 30% in some cases, Morgenstern-Gaines stated. The program has also helped reduce emergency department visits and hospitalizations and increased cost satisfaction ratings by nearly 95% among payers, she added.

“Something really unique about GUIDE is the specific focus on the family caregiver” Morgenstern-Gaines told Hospice News. “We know our system will break if we don’t support the family caregiver. So having respite be funded by traditional Medicare for the first time is a humungous milestone and huge testament to their work. It changes lives.”