Guiding an Improved Dementia Experience (GUIDE) Model

The GUIDE Model is a new program that supports eligible Medicare beneficiaries who are experiencing dementia. Enrolled beneficiaries and their caregivers receive care navigation and caregiver support services. The goal of the GUIDE Model is to improve quality of life, reduce caregiver burden and strain, and prevent or delay nursing home placement.

Enrolled GUIDE Model clients will work with their Care Navigator and interdisciplinary care team to develop a person-centered care plan. Clients will receive ongoing monitoring and support and will have access to a 24/7 help line. Education and support will be provided to caregivers, with respite services available (up to an annual cap) for eligible beneficiaries with moderate to severe dementia.

Bay Aging will begin accepting GUIDE Model clients in July 2025. In the meantime, we encourage potential enrollees to take advantage of our Caregiver Support program – to learn more and join our caregiver email list, call Bay Aging Intake at 800-493-0238.

Eligibility Guidelines

Determination of eligibility for GUIDE will be made by Medicare based on assessments that we will help clients complete. Enrolling in GUIDE does NOT impact your other Medicare benefits, and does not change your PCP or specialists. Medicare’s beneficiary eligibility criteria are:

• Client has a diagnosis of dementia (if dementia is suspected but not yet confirmed by clinician attestation, Bay Aging can assist you in getting a diagnosis)
• Client has Medicare as their primary payer and is enrolled in Medicare Parts A & B (including beneficiaries dually eligible for Medicare and Medicaid)
• Client is not enrolled in Medicare Advantage (including Special Needs Plans and PACE)
• Client is not enrolled in Medicare hospice benefit
• Client does not reside in a long-term nursing home

If you are NOT eligible but you need help, call us to learn about other services!

Resources for Caregivers

Bay Aging offers many resources to assist caregivers on their caregiving journey. You are not alone! Call 800-493-0238 to find out how Bay Aging can help you.