Early Lessons Learned Implementing the Dementia-Focused GUIDE Model

On July 1, 2024, the Centers for Medicare & Medicaid Services (CMS) Innovation Center launched the Guiding an Improved Dementia Experience (GUIDE) Model, with 330 participating organizations currently building dementia care programs serving hundreds of thousands of people with Medicare nationwide. At the recent fall meeting of the National Association of ACOs (NAACOS), Bluestone ACO’s Nate Hunkins, M.P.H., shared some early lessons learned in the program. 

The GUIDE Model is slated to run for eight years and is one of the first Innovation Center care models to focus on longitudinal, condition-specific comprehensive care, a key element of the Innovation Center’s 2022 Specialty Strategy. Today, nearly 7 million Americans live with Alzheimer’s disease or another form of dementia, and, by 2060 the number of Americans living with dementia is expected to double to 14 million.

Eighty-nine organizations began their performance period in the alternative payment model on July 1, 2024, while 241 organizations had a one-year pre-implementation period starting July 1, 2024, and began their performance on July 1, 2025.

Under the model, participants are assigning people with dementia and their caregivers to a care navigator who helps them access GUIDE services and supports and non-GUIDE services and supports including clinical services and non-clinical services such as meals and transportation through community-based organizations. Model participants are also helping caregivers access respite services, which enable them to take temporary breaks from their caregiving responsibilities.

GUIDE participants represent a wide range of providers, including large academic medical centers, small group practices, community-based organizations, health systems, hospice agencies, and other practices.

Speaking on a NAACOS panel, Hunkins first gave some background about Bluestone and why GUIDE made so much sense for them to participate in. “At Bluestone, we believe patients with complex chronic conditions deserve advanced primary care,” he said. “We provide primary care and focus on assisted living communities. Bluestone really is a niche provider in the sense that we're not in skilled nursing facilities. We do a little bit of independent living, but we are primarily an assisted living primary care organization across three markets — Minnesota, Florida and Wisconsin.”

Bluestone ACO saved Medicare $33.6 million in 2024 as part of the Medicare Shared Savings Program (MSSP) through its care for 5,772 Medicare beneficiaries who reside at assisted living, memory care, and group home communities. Bluestone ACO will expand its model in 2026 in partnership with Herself Health, a company providing comprehensive primary care to women as they age and mature.

The average age of Bluestone’s population is 82, with an average of seven chronic conditions. Approximately 65% of its patients are eligible for GUIDE.

“Whether or not to enter GUIDE felt like a pretty easy decision, conceptually, because this is a population that we serve at scale essentially,” he said. “We have care coordination. We call it complex care management. We've got behavioral health specialists who are integrating within our primary care. So when we looked at GUIDE, the real question was that we've got so much ancillary support within our advanced primary care model, how do we really fit in GUIDE so that we're not overlapping services and really contributing to greater costs within the healthcare system? We need to be able to deliver this efficiently. We have not figured that out perfectly, but that was the premise that we understood from the beginning — that this has to integrate with our model, not just be additive in terms of cost and extra services without true value to the patients.”

When Bluestone execs looked at which GUIDE services it is not offering within its advanced primary care model, they realized it was having a dedicated care navigation for all of the eligible residents and caregivers.

“Previously, we weren't doing a full needs assessment, including the SDOH component for our patients with dementia, so we did see that as an opportunity to leverage that information to provide more comprehensive care for our patients,” Hunkins said. “We saw that the dementia care navigator could actually take some of this advanced care planning from our primary care providers and help tee up some of that conversation and really work with the caregiver, along with the patient in having that conversation.”

Hunkins said another piece of this is being more sensitive to change in conditions. As an ACO, they want to ensure that they are preventing hospitalizations and the transition to long-term care. “We needed to make sure that our dementia care navigators were adding value around transitions of care. How are we ensuring that we're looping in the entire team to make the right decision on the right level of care for the patients?”

Even prior to the GUIDE model, Hunkins said, they estimated about 20% to 25% of their ED visits were avoidable. “What we've done is work on how we intervene upstream. Also, if our patients enter the ED, how do we intervene at the ED so that doesn't lead to an admission. Many people in the dementia population can't advocate for themselves. They can't actually articulate what their wishes are. We see that as our responsibility as primary care and a GUIDE participant —  to make sure that we're advocating alongside the caregiver, if they have one, to ensure they get the right level of care within the hospital setting, because the default for someone who can't articulate their needs is to get them admitted,” he explained. “We’re trying to make sure that we have documentation of what those patient wishes are, and then have care navigators, in collaboration with our complex care managers, intervening within that ED."

Essentially, Bluestone saw GUIDE as a lever for value-based care and overall ACO improvement. “For us, there really wasn't a question of whether we were going to do it, but it was a matter of how we can ensure this isn't going to be additive and lead to greater costs within our ACO,” Hunkins said. “We do think that avoiding hospitalizations and doing more proactive, advanced care planning are the levers to be able to create the offset of costs. With the PM/PM costs of the GUIDE care model, we felt pretty that if we could avoid one hospitalization in a year, that essentially would pay for this program. So that's the key. We are new participants, three months into the program, so we don't have the data that we're all looking for to ensure this really is adding value to the healthcare system, as opposed to just adding services without the value. But that’s the angle we've come at this from. We understand we're unique in the sense that 65% of our patients have dementia. But we really do want to be leaders in this space, because we've been delivering care to this population for going on 20 years now.”

From a GUIDE-specific perspective, one of the early lessons learned was that hiring was more challenging than Bluestone had anticipated. “Within the realm of care management, we have care coordinators, care managers and now care navigators. So I think it was introducing a new lexicon on care navigation that was tripping us up a little bit,” Hunkins said, “so we've had to play around with how we sell this position to folks who want to contribute to the betterment of dementia care.”

Another issue is patient resistance. Bluestone was expecting an 80% consent and enrollment rate. After all, this is a free benefit for Medicare patients, These are Bluestone’s primary care patients and 65% of them are eligible. “We thought this was going to be an actual slam-dunk in terms o getting the consent and enrollment,” he recalls. “What we found is that this was much more challenging at the individual patient level. We've run into a variety of things. Patients do not trust anything that's coming from the government.
We're saying this is a free benefit to you from your health plan for Medicare, and they think that we're trying to pull something on them. We've had to rework our language around that to say this is a Bluestone offering, and it's covered from your health plan.”

Also, sometimes families and patients still don't want to admit that they have dementia, he said. “When you lead with, 'Hey, this is the dementia program, people will say, ‘We don't want to talk about mom's dementia,’ so there is still national stigma around dementia, and we're encountering that, and we didn't really have that on our radar,” he said. “The nature of the conversation around dementia is still very sensitive, much different than diabetes or a different chronic condition that is a little more socially accepted, at least within society. So tweaking our language around how we present this program, how we describe it, and what benefits is offers all kind of tie into how we're addressing some of those consent challenges.”

Bluestone also had to convince its own providers about the program. “That’s another selling point that we didn't necessarily anticipate,” Hunkins said. “We knew we were going to have to tell our providers about the program. But providers are very similar to patients, in the sense that more isn't always better, because it complicates things. I think our providers thought if everything's going well, then why are we going to add this service? We've had to show our providers what sort of things are coming off of their plate that the care navigator can handle.”

Another area is communication with caregivers. Bluestone has a tool called the Bluestone Bridge. It is a essentially a virtual care conference that goes on between the assisted living nursing staff, home care or hospice, the caregiver and Bluestone providers. “It's an ongoing conversation virtually and our providers are central to that,” he said. “So when there's a change in condition, they're responding to it. What we've been able to do is deflect some of the traffic and the time that our providers are spending on that tool. Now we haven't perfected that either, but we know that that is a good opportunity for us to bring value back to our providers in terms of selling this program.”

Also, within the assisted living communities where Bluestone delivers care, it has to sell the program to them as well, so that they understand from their nursing staff perspective what value this is bringing to that community. “So much of what a patient within an assisted living community is dealing with does affect the nursing staff within the building,” Hunkins said, “so we want to, make sure that there's value add for the assisted living community within this program as well.”