UT Health San Antonio outlines physician‑led home‑visit model and Medicare GUIDE rollout for dementia care

SAN ANTONIO — UT Health San Antonio’s Biggs Institute presented an interdisciplinary, physician‑led model of home‑based and clinic care for older adults and people with dementia and described early operational results from implementing Medicare’s GUIDE dementia‑care model.

The CARINOS program (Compassionate, coordinated, and comprehensive care) centers the ambulatory clinic while linking hospital consults, inpatient rehabilitation and nursing facilities, home health and hospice agencies, community health workers (promotoras), and local partners such as the Alzheimer’s Association, said Dr. Angelica Davila, a physician with UT Health and the Biggs Institute. “Older adults are wise and they know what they want and we need to listen to what they say,” Davila said.

The presentation explained why the clinic prioritized home visits: transportation barriers and uneven access across South and West sides of San Antonio meant many patients could not reliably reach the North Side clinic. Davila said the practice now focuses on people living with dementia of any age and very frail adults 85 and older. “We are physician led, primary care,” she said, describing physician–nurse practitioner dyads that alternate home visits and the clinic’s use of community health workers for outreach.

Why it matters: The Biggs/UT Health model aims to reduce avoidable hospitalizations and keep people with dementia and their caregivers supported at home. Presenters stressed that the approach requires time, staff and interoperable workflows in Epic to schedule and document home care efficiently — constraints that affect finances and capacity.

Operational details and lessons learned: Davila said the clinic follows about 3,000 patients but considers that a small fraction of need in Greater San Antonio and South Texas. The practice currently includes five geriatric physicians and five nurse practitioners. Key barriers the team identified were scheduling and routing clinicians (largely manual today), longer visit times for home visits, and limited Medicare reimbursement for some home‑based work. Davila said the clinic partners with a private urgent‑care‑at‑home vendor (Dispatch Health) for some acute home needs.

Juliandra ("Julie") Bridal, an LVN and the program’s care team navigator, described implementing the GUIDE model, a voluntary CMS program for Medicare beneficiaries with dementia. She said GUIDE enrollment requires traditional Medicare (not Medicare Advantage or replacement plans) and cannot include patients on hospice or in long‑term care. Bridal described intake and documentation practices the clinic developed: a 25– to 30‑minute intake call using a standard template, caregiver‑burden screening (the 22‑question Zarit‑type instrument used informally in intake), and a comprehensive clinician assessment that can take 60–120 minutes depending on acuity and setting. “It’s a judgment free zone,” Bridal said of intake conversations with caregivers.

Outcomes and administrative details: Bridal said the clinic began submitting GUIDE enrollments in July and averaged 25–30 submissions per month initially, growing to roughly 30–40 as processes matured; she noted losses when patients changed insurance or later enrolled in hospice. She emphasized maintaining a clean spreadsheet and collecting caregiver data during intake to streamline the monthly Medicare submission process.

Role of social work and community services: Angela Torres, the clinic social worker, described support groups, counseling and community engagement (for example, collaboration with the San Antonio Alzheimer’s Association and museum programming) and highlighted funding gaps: services provided by social workers and community health workers are generally not reimbursed by Medicare, Medicaid or private insurers. “Respite and in‑home supports are typically private pay unless a family has long‑term care insurance,” Torres said.

Discussion and next steps: Presenters said scaling the model will require more clinicians, expanded interdisciplinary teams (social workers, community health workers, pharmacists and home‑based therapists), Epic integration for scheduling and billing, and sustainable funding. They suggested using GUIDE program data to document need and support requests for expanded federal or state funding for social services and in‑home care. Davila and colleagues noted efforts to extend services outside San Antonio (including Laredo) but said operational and acute‑care coverage barriers remain.

Ending: Presenters asked policymakers and funders to consider funding social work and community‑based supports, invest in scheduling and EHR integration, and expand workforce capacity if home‑based dementia care is to reach a larger share of the region’s older adults.