Additional Resources Mentioned
Takeaways
What the Medicare GUIDE Program Offers
- One-on-one support and coaching by dementia prevention providers
- Care navigation through an often difficult and chaotic healthcare system
- Education and training resources for caregivers
- Respite care
Tip 1: Understand Your Eligibility
Basic eligibility requirements:
- Must have Medicare Parts A and B
- Medicare Advantage not eligible: this may change down the road
- Cannot be in hospice:
- Cannot live in skilled nursing: but assisted living is okay
What you get when eligible:
- Comprehensive assessment by a dementia proficient provider
- Interdisciplinary team approach:
- Dedicated care navigator:
- Proactive support:
Additional services included:
- One-time home assessment
- Dedicated education and support for caregivers with working knowledge of each stage of the disease
- 24/7 support
- Care coordination
- Respite care: Up to $2,500 a year in paid respite care
Tip 2: How to Find a GUIDE Program Near Me
There are approximately 390 programs across the country, and they’re nicely scattered to ensure good coverage. Google “Medicare plus GUIDE plus dementia” and it pops up pretty easily
Tip 3: How to Integrate GUIDE with Your Existing Medical Team
Key questions to ask potential GUIDE programs:
- How will you coordinate with my existing specialists and medical team?
- What’s expected from me? (frequency of contact, office visits vs. telehealth vs. phone calls)
- What classes are available and how are they offered? (in person vs. Zoom vs. self-directed)
- What support groups do you offer?
Your responsibilities in the program:
- Ongoing assessments
- Be honest
- No long-term commitment required
About Emory’s Integrated Memory Care GUIDE Program
For those in the Atlanta area, Emory’s Integrated Memory Care is led by nurse practitioners who are all dementia specialists and geriatric specialists. They bring everything under one umbrella with geriatric psych, licensed social workers, and RNs on their team. This eliminates doctor hopping and multiple visits.
The clinic is located at North Druid Hills and Briarcliff in Executive Park, and they also have a community arm where nurse practitioners make house calls to various senior living communities around the large metro area.
Read More in This Blog here
Full Episode Transcript
Sue
Is the Medicare GUIDE Program for you? In this episode, Nancy and I are talking with Amy Imes of Emory’s Integrated Memory Care about the new Medicare Program GUIDE. We’re gonna be learning what it is and how to know if you can leverage it. We’re sharing three tips.
Nancy
Welcome Amy, we are so excited to have you. This is an awesome opportunity to talk about the US Medicare GUIDE Program. And if you’re listening on the day this is published, there’s a big lot of big announcements today, which is July 1 2025. So we’re excited to give you an overview so you can understand how you might participate in the GUIDE program. But first, let me introduce you to Amy, I’m going to read her bio.
Amy Eyes is a gerontological nurse practitioner who is a trusted expert in geriatrics, demonstrating a deep understanding of the unique healthcare needs of the aging population. Throughout her career, Amy has played a pivotal role in building care models, that’s important to the GUIDE program, and developing teams that yield superior outcomes. In addition to her clinical work, she is a member of the team at Emory’s Integrated Memory Care, which is a nurse practitioner-led primary care practice for patients living with dementia. She’s also the program lead for the Medicare GUIDE Program at Emory Healthcare.
Sounds like we have the right person today. So Amy, let’s start with, tell our listeners what GUIDE is.
Amy
Thanks for having me. I’d love to share all the innovation that’s happening in geriatrics. GUIDE stands for Guiding an Improved Dementia Experience. It is a US Medicare pilot program that aims to provide better support and resources for persons living with dementia and their caregivers. Which is awesome.
Nancy
And you heard Amy say it’s a pilot program. You’re going to find out how to join it. Please let’s all support it because we need to prove that this pilot program which focuses on helping dementia caregivers actually works so that this can become a standard part of Medicare. And can also be expanded globally. Yes, it would be ideal for the US to prove it’s worth so that we can help other countries take advantage of these kinds of support because they’re watching and they’re aware of it.
Amy
Thanks for those points. I think it’s really important to highlight that. This is a groundbreaking program that is being offered around the country. So definitely we want to show up and show out as people tend to say sometimes. The GUIDE program offers one-on-one support and coaching by dementia prevention providers, care navigation through an often difficult and chaotic healthcare system. Education and training and resources to caregivers, is much needed. Lots of tools and resources that we can share along the way. And also respite, which we’ll talk about a little bit later, the respite offering for Medicare beneficiaries is unprecedented, it’s never been done before, and it’s really, really exciting. As of today, July 1st, there are approximately 390 programs across the country that have been vetted by Medicare to provide this program, and so it is really, really gonna have an impact for persons living with dementia.
Sue
Which is huge because it’s fully funded by Medicare. And this is why Nancy and I prioritize this as something that really stands out because it’s the first time Medicare is recognizing the caregiver. And conservatively in the United States, there are over 12 million caregivers who are providing millions of hours of unpaid support and these are the family caregivers. Specifically for people living with dementia. Having it being recognized and doing such a responsible job of the program is incredible. And so this takes us to our first tip, which is if this sounds like something that you would be interested in, how do you find out if you’re eligible?
Amy
That’s a great question. To be eligible for the GUIDE program, patients need to have Medicare, both Medicare A and B. Medicare, traditional Medicare needs to be the primary payer since this is a Medicare pilot program. So unfortunately at this time, patients enroll or beneficiaries enrolled in Medicare Advantage aren’t eligible. We may see that change down the road. Patients cannot be enrolled in hospice and cannot live in a long-term care skilled nursing facility.
Nancy
But you can be like an assisted living.
Amy
Absolutely. But that is a good distinction. Although many of those terms get really blurred. What do you get? Like what’s the added benefit? It provides a comprehensive assessment by a dementia proficient provider. Medicare has done a really good job at requiring
providers that are touching patients and caregivers to actually be the experts in their field. That’s so important. The amount of vetting that we had to go through for that was, for those of us that have been working with dementia forever, is just, finally somebody’s listening to us, right?
There’s an entire interdisciplinary team, so that’s really important too, that it’s not just me out in the world providing support and care, which I always love to do, but there’s an entire team of people. And so we can really hit different aspects of people’s lives and caregiving. There is a care navigator, dedicated care navigator for each beneficiary and caregiver group. That is huge. I mean, there’s someone specific. Right. This program actually also requires that we’re proactive.
And so the care navigator is your person that’s gonna help you steer, or help you paddle down the river, or maybe it’s up the river. We often feel that we’re paddling up the river. But we’re not, you know, within this program, Medicare really realizes that caregivers are overwhelmed and extremely busy. And sometimes you don’t have time to stop and call and ask them questions. So I do love that they expect programs to be very proactive and reaching out, offering resources, and really being in tune to each individual’s needs. Well, and having someplace and someone to call is huge. It is really nice. And so that care navigator is just really going to be the one that’s going to sort of be the quarterback within the team. OK, although each of these participating programs are really the quarterback for your overall care.
There is a one-time home assessment that’s really just done sort of right after the time of enrollment into the GUIDE program. Sending somebody with a trained eye in to get a feel of what day-to-day look like for patients and caregivers.
Are there tweaks along the way? Anything that we could recommend that would help patients maintain their independence that would help make things easier for the caregiver. And I’ll tell you, in doing this last year, sometimes it’s just moving the nightlight from the hallway into the bathroom. You know, the other thing that’s my favorite thing that I’ve done for many patients is putting a picture of a commode on the door. Seriously, there are so many people that would never have known about that or thought you wouldn’t.
Also, GUIDE records of participating programs provide dedicated education and support for caregivers. I love that. And so each program is gonna you know come at that a little differently but you know thinking about really as a caregiver to have that working knowledge of each stage of the disease. Also knowing what to expect around the corner is extremely helpful. kidding. And so you don’t get caught off guard. Helping train people how to deal with those difficult behaviors.
That can really be very frustrating and put us into a crisis situation really quickly. So it’s ongoing training and support. This is an eight year pilot. So we’re gonna teach you and we’ll check on you. It’s really providing resources and so that shoulder to shoulder support.
Sue
Now when you say the pilot program you don’t have to be able to commit to it for eight years because you may not have that journey so clarify that a little bit.
Amy
Medicare has dedicated to fund this program for the next eight years which is important to be able to measure the interventions that we’re doing and what those outcomes are. There’s actually no commitment required for a GUIDE. It’s voluntary. It is really just an additional Medicare benefit. There’s no cost to patients.
They also require that we provide 24/7 support. We probably all have the Alzheimer’s 24-7 hotline number in our phones still probably, right? But that’s not always the tailored help that you need. I mean, it’s fantastic. It’s not personalized to the care that you’re getting. So they do require all of the participating programs to provide 24-7 support.
We talked about care coordination. This is a program that really aims at being the quarterback, being the overseer, the collector of all the things. And Medicare very actively expects these programs to coordinate with the existing medical team that patients have, making sure that hospital transfers and discharges or changes between care levels are very smooth.
Respite is where, as a caregiver you can step away and have somebody come in and actually take care of your loved one. Sounds wonderful. Right. This is a 24-7 job caregiving. You can’t just step away. You can’t just go away for a weekend. You know, everybody needs a little break from time to time. Medicare has never covered respite before. So along with this program, people that enroll within GUIDE are eligible for up to $2,500 a year in respite. Paid respite care to come in.
Certainly for patients who cannot be left alone, right? So patients at an earlier stage that are still fairly independent may not need that, you know, that level of oversight. Sure. GUIDE requires participating programs to provide at least in-home respite. So sending a paid caregiver in so people can get away, take a nap.
But participating programs can also use that respite benefit for adult day programs in patient respite. So those are available.
Nancy
So if I like hearing all this and all this sounds like something that would benefit me, then let’s talk about tip two, which is how do I find a GUIDE program near me? You just said there were 390 of them. that sounds like a lot, but maybe not. We’re a big country.
Amy
The good thing is that they’re nicely scattered across the country. It doesn’t seem to be too heavily populated in certain areas. Medicare designates the service area for each participating program. That’s just to ensure that if you’re going to provide this level of care, you’re going to provide this level of care. They don’t want people to over-promise.
Nancy
Does it need the geographic area that they can provide services in? So that’s important to note.
Amy
Medicare has a website for GUIDE. It’s a really long Medicare name. Government name. Website. But I usually just tell people to Google Medicare plus GUIDE plus dementia and it pops up pretty easily.
Nancy
That’s awesome. And then we’ll of course, as always put the link in the show notes.
Amy
I got a call from a caregiver a few weeks ago. his wife was away at her adult day program and he was just one of those forings and he just hit the end of his room.
And he called and he said, Amy, I’m literally sitting outside in the rain. I can’t, I just can’t do this today. And so we were able to help him, you know, set up a respite right around the corner. So you just take a break. But, um, I think every caregiver has that day. Oh yes. So multiple days or periods of time. um, it’s just been amazing to be able to provide that level of help that people don’t have to come out of pocket for.
Sue
It’s just incredible. So I’m very, very excited about that part. I think that’s absolutely excellent. And then one of the things that you had talked about is the medical team. For people who already have a medical care team, it would be helpful to find out how we integrate with them, and that happens to be tip three. So how do we integrate the GUIDE program with our existing medical team?
Amy
That’s a great question. This really should be a nice add-on or augmenting. Each program’s going to vary a little bit, right? And the depth of the level and management of what they’re providing. But because the requirement of documented care coordination, should be something that would easily just fit on to somebody’s existing medical team. So there wouldn’t be any conflict.
You want to ask the right questions, right? How do you know? I’ve just said that every program is going to do this a little differently. What’s going to make it fit for you? So I brought a list of questions.
I think the first question is – 1. How are you going to coordinate with my existing specialist in the medical team?
- What’s expected from me? So what’s the frequency look like? Do I come into an office? Is this through telehealth? Are these phone calls? Is this phone triage? So, know, if this is going to be the right fit.
Nancy
Even though there’s 390, which sometimes sounds like a lot and sometimes doesn’t when you think about the size of the country, there can be, if you’re in some geographies, could there be more than one GUIDE program participant?
Amy
There can be. So you do want to understand what these questions are. And because of what you just said, some are going to provide more service than others. So you need to understand which one fits best with what you’re looking for. Particularly in larger metropolitan areas, there are likely to be multiple GUIDE programs offerings.
Also in Georgia, there’s gonna be some rural overlap too, which is really nice. But you know, every geographical area is gonna be a little different. What exactly is available to us, right?
- So ask what are the classes and how are those offered? Are they in person? Are they via Zoom? Are they self-directed?
- What are the support groups? And I think what kind of support groups is also really important. Particularly in caregiving for patients with dementia, having that circle of support that really helps you care for your loved one with dementia. And I always explain it by saying, you know, if I’m a 30 year old daughter taking care of a mother with an early onset Alzheimer’s, maybe that Tuesday at 10 a.m. group of spouses taking care of their husbands, is it maybe gonna be the best fit for me?
Our patients and caregivers have a little bit of responsibility in this program as well. There’s ongoing assessments that will measure caregiver stress and burden, quality of life for persons living with dementia, staging of dementia along the way? Are there any health related social needs that are impacting care in any way so that we can develop resources?
Make sure you’re honest. Yeah, that’s because that’s gonna come right from you And so those assessments are gonna have to be at least annually and sometimes more of it we’re doing a reasonable though. They’re not in depth and number of questions, but they’re asking tough questions. And so it’s really really important for caregivers to answer this honestly, you really and truly, this is not the time to sugarcoat it. We need to show Medicare and the rest of the world to know how hard this is or how hard it can be. Just because your stress is managed
doesn’t mean that you’re not having stress?
Sue
And this is a pilot program. And it’s for those of us who are caregivers. So when you say tell it like it is and to be really honest about it because it is a big deal. And for us, training and respite really do matter. They really move the needle. And when we think about the impact that we can have in our lives, and then as this works in the lives of more people here in the United States, and then also around the world, this is huge. So it’s a great opportunity. I’m so thrilled that you’re sharing all this information with us.
Nancy
But there will be people who are in the Atlanta area, which is what Emory serves. So why don’t you tell us a little bit about Emory IMC in case people are interested specifically about your program. The Integrated Memory Care Clinic at Emory is a clinic really led by nurse practitioners. We’re all dementia specialists and geriatric specialists and we bring everything under one umbrella. So we have geriatric psych, we’ve got licensed social workers, and RNs on our team. It eliminates some of that doctor hopping or up and down the road visits. It was hard enough to get in the car one day. It’s definitely harder to get in the car three times. Our clinic is located at North Druid Hills and Briarcliff, right in Executive Park. But we also have a community arm of our clinic where the nurse practitioners are making house calls to various senior living communities around the large metro area. So that’s just been a really fun thing to participate in and we’d love to talk to you and ask some questions.
Nancy
This has been fantastic. Sue and I both felt like this was a really important topic and you have brought so much light to it. Thank you, thank you, thank you.
Amy
You’re so welcome. I just cannot stress enough, there’s really no downside for people joining the GUIDE program or enrolling in it. The more we put into a program like this, the more we’ll get out of it in the long run.
Sue
Well, Nancy and I would both have been right at the top of the list of volunteering if this had started a few years ago. So hopefully this can be a method of supporting other people being able to take advantage of something that they’re going to get so much benefit from.
Nancy
Well, let’s summarize. Today, Sue and I talked with Amy Imes about the U.S. Medicare GUIDE program and really all that it can do to help dementia family caregivers. We talked about three tips.
First, understand your eligibility and how to understand your eligibility.
Second, how to find a GUIDE program near you.
And third, how would the GUIDE program be incorporated into your existing medical team?
Now, if you’ve been a participant GUIDE already, or you know something about the GUIDE program, feel free to put any tips you might have on our Facebook page or our Instagram page. The links are in the show notes. We’ll also make sure the links to how to find the GUIDE program are in the show notes as well.
Now remember also any podcast, just look at the number of the podcast. And if you go to thecaregiverjourney.org, you look at the blog portion of our site, there’s a matching blog. So we’ve effectively taken notes for you. So you don’t have to take notes and remember everything we said on this podcast. Just go print off the blog.
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