Since the press release about the new CMS Dementia GUIDE model on July 31, more info has become available on the model. Below are highlights that stood out to us that clarifies who's eligible to participate, care delivery requirements, and payment. (If you're interested in the basics on the model, scroll to the bottom of this post).
- Nearly all model components can be delivered virtually. One in-home visit is required for some beneficiaries when they first join the model. Beyond that, there is flexibility in the model for in-person or virtual delivery of services.
- Medicare Part B providers can participate and sub-contract with non-Part B vendors to deliver model components. While named and billing participants can only be Medicare Part B providers, Home & Community Based providers and other vendors can be sub-contracted to help deliver the model. CMS mentioned Caregiver Training as an example when they may choose a vendor. Only Part B providers can bill. Providers participating in other CMS models (e.g., ACO REACH, MSSP) can still be part of GUIDE, and multiple providers can collaborate to fill the model components.
- The care team needs a Clinician with dementia experience and a Care Navigators who's received training on dementia topics. The clinician needs to have either a 25%+ panel size of patients with cognitive impairment or over the age of 65, or specialized education like geriatrics. The Care Navigators don't need a credential or professional accreditation. The only requirement is training on the dementia care model topics.
- Caregiver training is not standardized in the model. Participants can create their own training or work with a vendor to provide training.
- PMPM base rate ranges from $150-$390 PMPM for the first 6 months and $65-$220 for the following months. The payment rates depend on complexity of the patient and whether a caregiver is involved. There are 2 PMPM rate adjustments: a Health Equity Adjustment and a Performance Based Adjustment.
- The 5 performance metrics cross patient, caregiver, and system and are as follows:
- Zarit Burden survey for caregivers (survey based)
- Quality of life for patients (survey based)
- High-risk medications (eCQM/CQM)
- Total Per Capita Cost (claims)
- Long-term nursing home stay rate (claims-based)
Reminder that non-binding letters of interest are due by Sep 15. If you're a Part B organization interested in our services, please reach out to firstname.lastname@example.org.
Summary of CMS Dementia GUIDE:
(initial post from early Aug)
CMS has opened the gates to reimbursing services for family caregivers, and the Dementia GUIDE model is the latest example of this. Dementia affects 6.7M people today and millions more family & friends around them. The GUIDE model draws from programs and research that have demonstrated benefits to people with dementia, their caregivers, and the broader system (e.g., by reducing nursing home utilization). A quick summary of the GUIDE model is below.
GUIDE model attributes:
- Payment model: Medicare Part B will pay providers on a Per Beneficiary Per Month basis if they deliver the services required in the GUIDE model. The rates will be adjusted by a Health Equity Adjustment and Performance Based Adjustment. Respite services will be paid separately for a subset of beneficiaries. Finally, participants setting up new dementia care programs will receive a one-time infrastructure payment.
- Performance measures: Performance measures will include beneficiary quality of life and caregiver burden. Additional performance measures are still to be communicated.
- Eligibility: Medicare Part B providers & suppliers excluding DME and lab can participate. This excludes Medicare Advantage, PACE, and Special Needs Plans. Providers with or without a dementia program today can participate, though have different tracks.
- Services: Providers need to deliver all components of the GUIDE model to receive the payment. They can contract with other Medicare Part B providers to fulfill all model requirements if they cannot deliver all themselves. Required services include:
- Care navigator to connect patients and caregivers to clinical and non-clinical community resources (e.g., meals, transportation). Screening for psychosocial and health-related social needs will be required to identify the best resources,
- Person-centered assessments & care plans, and care coordination
-Evidence-based training & support for caregivers, such as training on best practices to support a loved one.
-24/7 access to a support line for caregivers.
-Respite services so caregivers can have temporary breaks. Respite could include care at home, adult day care, or facility-based care.
- Timing: The program will start in July 2024 and run for 8 years. Non-binding letters of interest are open through September 15 and then applications will open up later in the year.