What is the GUIDE Model – and How Can Non-Medical Home Care Agencies Participate?
Published on October 13, 2025 by Dan Wenger
Across the United States, an estimated 7.2 million people are living with Alzheimer’s disease or another form of dementia — a number that’s expected to double in the coming decades.
For families, the impact goes far beyond medical needs. Daily care, emotional strain, and financial pressures often fall on the shoulders of unpaid family members who are doing their best to support loved ones at home.
Recognizing this growing challenge, the Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model in July 2024.
This voluntary, nationwide initiative is offered in all U.S. states, territories, and the District of Columbia, and aims to transform how dementia care is delivered and supported.
In this blog, we’ll unpack the GUIDE Model: what it is, how it works, who’s eligible to participate, and the key benefits it aims to deliver. We’ll also explore how non-medical home care agencies can get involved and the role Aaniie Care can play in ensuring GUIDE-readiness and success.
What is the CMS GUIDE Model?
The GUIDE Model is a new eight-year demonstration from CMS’s Innovation Center. Its purpose is to test a more structured, comprehensive dementia care package under Medicare — designed to improve quality of life for people living with dementia and better support unpaid caregivers who provide their care at home.
Unlike traditional medical programs that focus mainly on clinical treatment, GUIDE takes a more holistic approach to dementia care. It brings together medical, behavioral, and social supports — along with care management, caregiver education, and respite options — to provide a more coordinated, person-centered experience for families navigating dementia.
Under the model, each participating organization — known as a ‘GUIDE Participant’ — is responsible for:
- Providing an array of comprehensive assessments.
- Managing care planning and coordination across multiple providers.
- Offering around-the-clock access to dementia support and crisis response.
- Providing education, training, resources, and respite opportunities for unpaid caregivers.
- Guiding families through changes as dementia progresses.
There are currently 330 organizations participating in the model, as announced by CMS on July 8, 2025.
In addition to improving outcomes for individuals living with dementia, CMS will also evaluate the model’s ability to:
- Reduce unnecessary hospitalizations and emergency visits.
- Prevent or delay long-term nursing home stays.
- Lower overall healthcare costs.
- Enhance quality of life for both dementia clients and their family caregivers.
The GUIDE Model reflects a broader shift toward value-based, person-centered care — one that recognizes that quality dementia care depends as much on service coordination and caregiver support as it does on clinical expertise.
Core components of the GUIDE Model
Each GUIDE Participant/Agency must deliver a set of core services, designed to meet both clinical and non-clinical needs. These include:
- Comprehensive assessment and care planning: Every person living with dementia receives a personalized care plan, developed by a dedicated interdisciplinary team based on their medical, behavioral, and social needs.
- Ongoing care coordination: A dementia care coordinator helps manage appointments, monitor changes, and connect families with appropriate services — ensuring care remains continuous and responsive.
- 24/7 access to help and crisis support: Families and caregivers can reach their care team at any time for guidance, symptom management, or emergency support, reducing the need for hospital visits.
- Education and support for unpaid caregivers: Unpaid family caregivers receive coaching, training, and resources to help them provide safe and effective care while managing stress and preventing burnout. This includes access to a personal care navigator and support groups.
- Respite services: GUIDE offers structured respite options to give family caregivers temporary relief from their daily responsibilities — an essential safeguard against burnout.
- Referrals to community and social supports: GUIDE Participants connect families to additional resources such as transportation, meal programs, or home modifications to further improve safety and support independence.
Each GUIDE Participant/Agency builds its own interdisciplinary team to deliver these services, which may include other providers, suppliers, and organizations, known as ‘Partner Organizations’. This includes contracting with community-based organizations that already deliver home- and community-based services and supports. Together, they ensure care plans are created, coordinated, updated, and aligned with each family’s specific needs and preferences.
Who the GUIDE Model supports — eligibility and exclusions
To qualify for the GUIDE model, individuals must meet the following basic criteria:
- Have a formal diagnosis of dementia — at any stage (mild, moderate, or severe) — as confirmed by a clinician affiliated with a GUIDE Participant organization.
- Be enrolled in Medicare (Parts A and B) and have Medicare as their primary payer.
- Live in the community, meaning living in their own home or in another non-institutional setting (such as an assisted living facility).
- Have not elected the Medicare hospice benefit.
- May be dually eligible for both Medicare and Medicaid, as long as Medicare remains the primary insurance.
GUIDE recognizes that every family’s circumstances are different. The model accommodates two groups of participants:
- Beneficiaries with an identified unpaid caregiver, often a spouse, adult child, or other family member who provides day-to-day support.
- Beneficiaries without an unpaid caregiver, who can still participate and receive care coordination and direct support through the GUIDE care team.
Participation is voluntary. Individuals must provide informed consent to be aligned with a GUIDE Participant. Once aligned, CMS verifies eligibility before GUIDE services begin.
Participants remain free to use other Medicare providers outside the model.
Exclusions apply to individuals who:
- Are enrolled in a Medicare Advantage plan or PACE program.
- Live permanently in a nursing facility or other long-term care setting.
- Have elected the Medicare hospice benefit.
- Move outside of the service area or revoke consent to participate.
By focusing on community-dwelling individuals with dementia and their unpaid caregivers, GUIDE seeks to fill critical care gaps that exist between medical management, social supports, and daily caregiving needs — helping dementia patients remain safely at home for as long as possible.
Why the GUIDE Model matters — key benefits
Dementia care in the United States has long been fragmented — often leaving families to navigate a maze of specialists, social services, and support programs on their own. The GUIDE Model represents a significant shift in how dementia care is organized, funded, and supported under Medicare.
Some of the key goals and benefits include:
Better coordination and continuity of care
GUIDE formalizes communication and care coordination across medical providers, social workers, and community-based organizations, so clients and families experience smoother, more reliable support — reducing hospital visits, avoiding care gaps, and improving day-to-day life.
Enhanced support for unpaid caregivers
Through structured education, skills training, respite services, and 24/7 access to dementia care navigators, unpaid caregivers feel less isolated, more confident, and better able to sustain care at home.
Equity in access
The nationwide rollout makes high-quality dementia care more consistent and accessible across all states and communities, including underserved populations who may not have had access to dementia-specific resources in the past.
Improved quality of life
By combining proactive care planning with emotional and practical support, GUIDE helps individuals with dementia remain safely in their homes longer, maintaining independence and dignity for as long as possible.
Cost and system efficiency
CMS will use the model to evaluate whether integrated, person-centered dementia care can reduce costly hospitalizations, delay long-term nursing home placement, and lower overall healthcare costs — while improving family satisfaction and outcomes.
The GUIDE Model is not just a new program; it’s a test case for the future of dementia care in America — one that prioritizes compassion, coordination, and community partnerships as essential elements of high-quality care.
Opportunities for non-medical home care providers
GUIDE Participants/Agencies are encouraged to form partnerships with local service providers to strengthen care coordination and help beneficiaries receive the full range of dementia support services they need.
Home care agencies are a natural fit for these partnerships as they already provide many of the day-to-day supports that align closely with the GUIDE Model’s goals — such as assistance with activities of daily living (ADLs), personal care, meal preparation, medication reminders, companionship, and observation of changes in behavior or health status.
These services not only help dementia patients maintain dignity and independence but also give unpaid caregivers much-needed support, respite, and peace of mind.
They also create new opportunities for home care agencies to collaborate, align care delivery, and demonstrate their value as trusted community partners, including:
- Supporting care plan delivery: Agencies can help implement elements of the person-centered care plan developed by GUIDE teams — providing consistent, reliable daily support while communicating key observations back to the main care coordinator.
- Enhancing respite capacity: GUIDE provides unpaid caregivers with respite services. Home care agencies can supply qualified, trained caregivers to fill these short-term care needs when family members need time off.
- Providing insights from the home: Professional caregivers are often the first to notice subtle behavioral or physical changes. Their observations can help GUIDE care teams in promptly adjusting care plans to prevent issues escalating or requiring emergency visits.
- Coordinating with community resources: Many agencies already collaborate with local senior services, transportation providers, and social programs. These existing relationships make home care agencies valuable connectors within the broader network GUIDE seeks to build.
- Contributing to caregiver education: Agencies with dementia-trained caregivers can help teach best practices to family caregivers, reinforce safe care techniques, and ease family stress.
The GUIDE Model opens the door to new opportunities for non-medical home care agencies — and with the right preparation, they can become indispensable partners in supporting families living with dementia.
How home care agencies can get involved with the GUIDE Model
Currently, home care agencies cannot enroll directly as GUIDE Participants, but they can still play a central role as Partner Organizations. Here’s how to get involved:
1. Identify the GUIDE Participant in your area
Start by finding the organization leading the GUIDE Model in your region. CMS provides a public list of all current GUIDE Participants — ranging from hospitals and health systems to medical groups and community-based entities.
These organizations hold the primary contracts with CMS and are actively seeking local partners to help deliver services in clients’ homes.
2. Reach out and explore partnership opportunities
Once you’ve identified your local GUIDE Participant, reach out to introduce your agency and express interest in collaboration. Highlight your experience in dementia care, respite services, and supporting unpaid family caregivers. Underscore your reliability, training standards, and ability to provide consistent communication and feedback to the care coordination team.
3. Demonstrate alignment with GUIDE goals
GUIDE emphasizes comprehensive, coordinated support that bridges medical and non-medical care. Where possible, showcase how your agency already supports this mission — for example, through assistance with daily living activities, observation of health and behavioral changes, companionship, and working collaboratively with family caregivers. Position your agency as a trusted extension of the larger care team, enhancing quality of life for both clients and families.
4. Ensure your agency is GUIDE-ready
GUIDE Participants will look for partners who are organized, tech-enabled, and ready to scale. Before formally entering into a partnership, evaluate your agency’s readiness to handle this new revenue stream. This includes having:
- The right infrastructure — for example, digital scheduling, electronic care plans, secure communication tools, and data-sharing capabilities.
- A strong team — for example, caregivers who are trained in dementia care, communication strategies, and managing behavioral changes with compassion and confidence.
When your agency can demonstrate both operational efficiency and a highly-skilled, stable workforce, you signal that you’re ready to integrate smoothly into the GUIDE framework.
5. Build lasting partnerships that create mutual value
Once partnerships are established, focus on maintaining ongoing relationships with your GUIDE Participant and other care collaborators, and look for ways to create mutual value. By actively nurturing these relationships, you can build trust and visibility within the GUIDE network — opening doors to new funding streams, stronger referral partnerships, and greater credibility as a valued community care provider.
By following these steps, you can confidently position your agency as an essential partner in delivering the coordinated, compassionate dementia care the GUIDE Model was designed to achieve.
Setting your agency up for GUIDE success with Aaniie
Becoming GUIDE-ready requires more than a willingness to collaborate — it requires a proper infrastructure and strong caregiver team. That’s where Aaniie Care comes in.
Aaniie Care (formerly Smartcare Software) is an all-in-one home care management platform built to help agencies streamline operations, strengthen caregiver engagement, and maintain compliance — all essential for functioning as an effective GUIDE partner.
With Aaniie Care, agencies can manage every aspect of care delivery, including:
- Digital care plans and task management tools
- Real-time shift scheduling and time tracking
- HIPAA-compliant communication with clients, families, and GUIDE teams
Once care services have been delivered, Aaniie’s integrated billing tools make partner invoicing and reimbursement quick, easy, and accurate. From post-service compliance verification to generating accurate invoices and processing payments, Aaniie Care streamlines billing workflows, improves cash flow, and saves agencies time.
GUIDE partnerships also depend on accurate data, clear reporting, and smooth coordination across multiple organizations. Aaniie Care supports this through:
- Automated reporting and visit tracking
- Real-time updates from the field
- Customizable KPI dashboards for internal monitoring of performance, productivity, and outcomes
- Secure, role-based access for caregivers, supervisors, and partner organizations
Beyond operations, Aaniie Care also helps agencies build and retain a dementia-ready workforce. The platform supports every stage of the caregiver journey — from recruitment and training to ongoing engagement — ensuring agencies can maintain a stable, skilled team ready to deliver GUIDE-aligned care.
- Recruit and onboard qualified caregivers through Aaniie’s ENGAGE Hiring Hub ATS tools
- Deliver and track integrated dementia-care training modules
- Monitor caregiver certifications, education, and performance
- Identify skills gaps for targeted upskilling or refresher training
- Reinforce engagement and retention through built-in communication and rewards tools
For agencies looking to provide ongoing in-home assistance and respite care under the GUIDE Model, Aaniie Care makes scaling services simple and sustainable.
Are you ready to partner, perform, and grow successfully with Aaniie?