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CMS’S GUIDE model shows large reductions in institutional care in early implementer report
Summary
Five Star Home Health, a GUIDE participant, reported Year 1 results showing 84% fewer long‑term care SNF admissions and 29% lower per‑capita costs among enrolled Medicare beneficiaries; CMS’s GUIDE program is testing longitudinal dementia care delivery and respite supports across ~330 organizations.
Five Star Home Health and partners presented early real‑world results from the Centers for Medicare & Medicaid Services’ GUIDE model, a CMMI Innovation Center test that pays a per‑member monthly navigation fee to support dementia care coordination, caregiver education and respite.
Johnny Wilkinson, founder and CEO of Five Star, reported their Year 1 results to the NAPA Advisory Council: among 209 patients enrolled, GUIDE‑enrolled beneficiaries experienced an 84% lower rate of admission to long‑term care skilled nursing facilities compared with matched risk profiles and 29% lower total per‑capita costs. Jodi Lyons, lead care navigator, said the program’s activities include in‑home assessments, monthly contact, fall‑risk and home‑safety evaluations, medication review, care plans, and respite support.
Lyons shared case studies where navigator intervention avoided emergency calls and helped implement safety plans for patients with frontotemporal dementia. GUIDE participants identified strengths (longitudinal care, caregiver planning) and challenges (onboarding burdens, program starting too late in disease course, demand for more respite). Lyons and Five Star urged expanding access to earlier stages of cognitive impairment and easing administrative onboarding.
Sarah Irie of the CMMI Innovation Center summarized GUIDE: two tracks (established and new programs), roughly 330 participating organizations in 44 states, and an eight‑year model projected to reach more than 200,000 Medicare beneficiaries. Participants noted persistent barriers including neurology appointment backlogs and misinformation on social media that complicate referrals.
CMS officials and council members discussed options to increase referrals and clinician awareness, and to streamline enrollment so programs can engage people earlier in the disease trajectory.
