Advancing Care Management: Applying the GUIDE Model in Dementia Care

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Daniel Marino:

Welcome to value-based care insights. I'm your host, Daniel Marino. As we talk about different population health topics, or value-based care topics most of the time we talk about those around certain conditions and how we need to manage those conditions. And in particular, we often focus on the rising risk population or the high-risk population. But there is a large segment of the of our population that either may not have necessarily a chronic condition or have a condition which oftentimes needs a lot of care but doesn't necessarily have the reimbursement. And I'm particularly talking about patients who have dementia or Alzheimer's, and it really does take a toll on not only the patients who have dementia or Alzheimer's, but it takes a tremendous toll on the caregivers and the thing that we struggle with as an industry is the support around patients with dementia and with Alzheimer's, and particularly the financial support, there is really not reimbursable by Medicare and even by Medicare advantage. And yet we see the numbers increasing. Right now, there's approximately about 6.7 million Americans who have some form of Alzheimer's or dementia, and that number is only expected to grow as our population ages. Well, CMS. Has recognized this, and over the last year has put forth a new innovation project. I'm really excited to talk about this today. It's called the GUIDE model. It stands for guiding and improved dementia experience. There's been a number of organizations through this innovation concept offered by CMS. That has been awarded as a recipient to manage it.

One of our well, our guest today is from JVS Health. JVS has been awarded as a recipient of the guide model. I'm excited today to invite Vanessa Guzman. Vanessa has been on the program before. She is a industry leader in population health and is CEO of Smartrise Health also joined by our partner, Seth Hyman, who's co-founder of JVS Health. And again, just, Seth has had a lot of experience in working with different ACOs around the country. Vanessa, Seth, welcome to the program.

 

Vanessa Guzman:

Thank you for having us

 

Seth Hyman:

Thanks for having me. Thanks for having us, man. It's good to be here.

 

Daniel Marino:

Well, I have. I have to tell you. I think everybody, either indirectly in your family, or we all know somebody who has some form of dementia. Whether it's like dementia or it's advanced dementia. It takes a significant toll on the families. And I was when we started to 1st talk about this, I really did get excited just because I feel like this is such a need that really we, we need to embrace as a healthcare industry and as healthcare providers. Maybe, Vanessa, we could turn to you. Can you give just a little bit of background on the GUIDE program and sort of the goals.

 

Vanessa Guzman:

Yeah, the model. And thanks again, Dan, for having us, because it's such an important discussion because one of the biggest challenges in dementia care has been the lack of consistent care and consistent support, especially for caregivers. So what this model does is it convenes and integrates 3 key components that from my perspective are key success factors for any dementia program. One is standardized assessment and care planning, and how you deliver those services that are appropriate for dementia patients and their families. It does include also interdisciplinary care that integrates not only services that are delivered at home, but wraparound services for both the caregiver and the patient, and it also includes a training component to support the caregiver. You know those are core factors that I feel will stand up any program for any population, but especially for dementia. From a from a services delivery perspective. It delivers 2 main things. There's care coordination, and, as you all know Dan working with ACOs across the country, one of the biggest challenges that we always bump into is helping patients navigate the complexities of any health system. But when a relative or a loved one or family member friend is diagnosed with dementia, there is confusion across not only taxes the care, but to really understand. What exactly do I need to care for my loved one? Right? So the care coordination is a key component, and then the other component is the actual caregiver services that are provided which include assessment and planning community resources and then access to support line 24/7 within what's appropriate for the for the dementia patient.

 

Daniel Marino:

Well. And you're absolutely right, Vanessa. I think one of the key things that I really appreciate about the program is it provides a direction to the caregivers right? Because many of the caregivers you're right. They don't know where to go, and unless the patient has some type of a health condition, you know, and many of them don't. Many of the patients who have dementia or Alzheimer's may be perfectly healthy right unless they have a condition. Where do they go for support? Right? And there's just there's just nothing out there.

 

Vanessa Guzman:

Nothing out there.

 

Daniel Marino:

So. So, Seth, let me let me turn to you. Talk a little bit about the specifics of the caregiver support. Right? Because I'm assuming the program has quite a bit of resources that are available to it. What are some of those resources that that would be available to the caregivers.

 

Seth Hyman:

Yeah, exactly. You're exactly right. And I think what differentiates this program, and what we're so excited about is the is the care navigators. That's really the engine or the driving force of this program is that every family, every patient, is going to have a 1 on one relationship with the care navigator. So it's not, It's different than some other chronic care management programs where you might have a nurse that you talk to once a month and then every month it's a different nurse. This is really a program tailored to the specific needs of the family and the care and the care recipient. So those care navigators will be able to, as Vanessa kind of touched on, do everything from coordinating transportation, coordinating meals, coordinating care between the specialties. Right? Sometimes these folks will have multiple different providers, and it becomes overwhelming, just keeping all the visits in order. So having that one-on-one relationship is really going to be a very something that's very beneficial for these families. So we're very excited about that. And of course, we're, going to you know, utilize our technology to do it in a way that makes it convenient for these families.

 

Daniel Marino:

So, you know. Let me share a quick story with you. You know I have a good friend of mine and his parents were in their mid to upper seventies, and his father came down with dementia. And his mother, you know. Bless her soul! Did a fantastic job of really taking care of his father, and but it would have created such a strain on his mother, and as much as the family tried to intervene and provide the level of support. It was hard, right, because she was taking care of her husband. 24/7, you know. I know that there's included in the program. I've read that there's respite services. There's other care services that would be provided. Seth, what are some of the things that would be included as part of the guide model?

 

Seth Hyman:

Yeah. So the thing that one of the aspects of this program that we're most excited about and everyone is most excited about is the respite care. So this is the 1st time that CMS is paying for any sort of respite care, and what that means is home care, adult day centers, or even a stay in a facility. So this is the 1st time they've done it, and there's no cost to the patients. So any Medicare beneficiary is eligible. As long as they have traditional Medicare they're eligible for the program. There's no cost, no cost, sharing no copays, no deductibles, nothing like that. So, being able to provide that sort of relief just you know you were mentioning your friend. You know we all have someone. My grandfather. I was taking care of my grandmother with dementia, and it's just, you know, little things like you don't have time to go get a haircut right? You don't have time to do anything. So, being able to provide these free home health services, even for a couple hours a week, is going to be such a game changer for these folks and we are just so excited about that, so we will work again with the family to come up with an offering that works for them, you know. If they want some portion it to be home health, some portion to be stay in a 10 day facility stay in a facility for 10 days where you know, they're going on vacation or something like that. We'll work with them to manage those resources and provide the resources that work best for the family. So the respite care. I can't stress enough. You know how excited we are about that. And I think once people hear about it, you know, their eyes light up because it's like this is something they've been needing.

 

Daniel Marino:

Yeah, absolutely, absolutely. And it just, you know, it just provides that additional support. And, as you mentioned, it, does provide some needed support to the caregivers. But what I like particularly about the program is that there's really 2 key aspects that drive the care plan for our patients with dementia and Alzheimer's. And it's really that care coordination between the providers and it's the caregiver services. I think those are absolutely key, and as many healthcare providers are working through their care management, this, you know, I could see, being a natural progression of how we want to manage care for patients who do have dementia and Alzheimer's. How do patients get enrolled? Right? You know this is a free service, but you know, at the end of the day Medicare is paying for this right? So at some point, you know, we need to be able to connect the dots around what the funds phone economic model look like, how do patients get enrolled into the program?

 

Vanessa Guzman:

Yeah. So there are a few pathways where patients can be enrolled. The 1st one is, and regardless of pathway chosen, is a diagnosis of dementia based on a care assessment that is designed to help identify the severity according to their unapproved clinician that will determine the level of effort or level of services provided to each patient. With that diagnosis. either the patient caregiver or provider can refer the patient to the program to a participant like JVS Health, which, and then we'll kick off a series of next steps and enrollment and engagement, including providing with the caregiver or the patient or the provider, with an overview of how the program works. Of course, Cms. Has dedicated much resources and providing participants like JVS Health with data to also help us identify the opportunities to engage families in care that potentially don't know about the program. You know I think one of the challenges that we will face inevitably is that most families that have a loved one or is caring for someone with dementia is that they don't even know where to start. So we really want to be proactive with working with providers this entire year, going into July, which is when we kick off the program officially, to raise awareness that this actually exists so that they can carry on effective conversations with their providers. So that this is this program is integrated into their primary care, into their specialty care. This should not be like a standalone thing in order for it to be as effective as it can be. It has to work closely with the providers as well. So a number of ways to get referred. But we all need to have a proactive role in making sure. We raise awareness in order for families to know that we even exist.

 

Daniel Marino:

Take advantage of it. Know that this is out there. If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today talking with Vanessa Guzman and Seth Hyman, and we're discussing the newly launched GUIDE model that's being offered through CMS. Seth, one as Vanessa was talking about the program, I guess one thing that came to mind is, how does that integrate with our with the current CMS ACOs that are out there? I would imagine some of these Medicare patients are part of ACOs or part of Medicare advantage. Is this a separate ACO for dementia patients? Or how does it integrate with the current ACO structure?

 

Seth Hyman:

That's a fantastic question. And I'm glad you asked that because CMS has designed this to be a parallel program with other ACOs or other MSSP programs like ACO REACH, for example. So they actually want patients to participate in both. So just because the patient is in an ACO is participating in an ACO through their provider or a health organization. they could still be enrolled in a GUIDE program. And, in fact, CMS just announced, which was, which is great news that the respite payments will not factor in to the benchmarks for those patients.

 

Daniel Marino:

That's great!

 

Seth Hyman:

They are really encouraging folks to get signed up for the GUIDE model, and for other. We're actually in discussions with other ACOs to kind of work with them, and to get their dementia population to come, join and join up with the GUIDE, because they see the value in this. They see, you know, we could help reduce the total cost of care for these folks by devoting minimal resources. And a lot of time. What happens is a lot of times patients with dementia Alzheimer's end up in the emergency room frequently. Just because they're having an episode and the family doesn't know what to do, so they take them to the emergency room. And as you know that so those are some of the highest drivers of cost. So, for example, if we have this 24 hotline that they could just call and sort of alleviate some of the stress that they're feeling we could help to maybe reduce some of those hospitalizations and ultimately delay, you know, admission to a skilled nursing facility as well. That's the one of the main goals of the program. So it's really designed to work with the MSSP program and other value based care programs. And they really are. They want us to have that integration.

 

Daniel Marino:

I think. Oh, go ahead, Vanessa. I'm sorry.

 

Vanessa Guzman:

No, I just wanted to make a note that it's the way that it's designed It requires participants to infuse or integrate a health equity plan. Which is huge. Right? Because when we're thinking about innovation models like ahead or ACO REACH, that's very much baked in there as well not to mention that in value-based care several States are requiring health, equity, accreditation. So my point is that there's infrastructure that ACOs, or those in the journey of value-based care can leverage and help advance via, you know, participating or enrolling patients helping us enroll patients in this model. My dad has dementia. He was diagnosed 11 years ago. I am Latina all the way. My parents are both Dominican. They only speak Spanish. My mom has been caring for my Dad for 11 years. Putting aside her own priorities, as you mentioned in your story, Dan, and we could see we've seen a decline in her own health. She misses appointments all the time, because there's something going on with him, and that takes priority in her world, and the fact that we can tailor the services based on the caregiver needs from a cultural appropriateness perspective, that that fills my heart because this is not just going to work magically. Via, oh, we have a program. And now we're going to provide you with resources. It has to carry the right naming, shared language, appropriate language, right for non English speakers, for instance, and the trust we have to be able to like the trust of our communities for us to engage their care. One of their loved one or the person they're caring for. Otherwise we won't be successful. So I just wanted to point out the equity piece of this is integral to the success of the program.

 

Daniel Marino:

Absolutely and to your point. It certainly does have to be multifaceted where it really aligns with what the care needs are of the community the care needs are of, you know I would say, of this population, because, you know again, when you think about it, the demographics associated with dementia, you know, I mean, you hear patients who, you know it's tough to say. But there's patients, even in their late fifties, early sixties who have dementia versus those that are are much older in life who have dementia. So I think it does have to be multifaceted, and I think this could be, as I see it a tremendous opportunity for ACOs, who do have a large attributed population within their ACO to be an extension of managing patients. I think it has a real opportunity associated with it.

 

Vanessa Guzman:

Absolutely.

 

Daniel Marino:

So let's talk a little bit about some of the funds flow, because I think this becomes important. This is a free service, right? But primary care, or somewhere, the physician has to be able to either refer or recommend, or if a patient, your caregiver does you know self-refer? How do the economics work, I mean are, are is JVS Health getting support from this? Or do primary care still can build the same way at a high level, you know. Maybe, Seth, you could address this. How does the funds flow work?

 

Seth Hyman:

Yeah, absolutely. So there are CMS is design UG codes specifically for the GUIDE model that only GUIDE participant, that only GUIDE participants are able to bill for so and that's on the respite side, and also for the for the monthly per beneficiary per month payments as well in terms of how primary. This won't affect the primary care providers, though at all. So they continue to see that, you know, we want to stress this. We can't stress this enough. Continue to see the patients the way they normally would doesn't affect any billing or any care that they're providing to their patients. Whether that be primary care, neurology, geriatricians, whomever they continue to just see the patients where they normally would. But they could just.

 

Daniel Marino:

So they continue the patient. They continue to treat the patients for every condition that they have, and they continue to bill, you know, as they normally have fee for service code. Still, you know, still work the same. So you know they're not, they're not limited, based on their reimbursement, based on patients enrolled in the program.

 

Seth Hyman:

Exactly. We wanna do not want anyone to think that we're trying to take over the care of these patients. We are not practicing medicine, we are strictly providing support for those for these families and these patients, and just providing additional resources. And you know, as we know, our other partner, Dr. Hyman. He's been a primary care practicing primary care physician, for, you know almost 40 years now, and a lot of times he feels overwhelmed when he gets, you know, a new patient with a new diagnosis of dementia. It breaks his heart because he does not know what to tell the families. He doesn't have the resources to kind of help them. So I think we have a real opportunity to help and be a great partner to primary care physicians all through, or any primary care provider throughout the country, and help them manage these patients and give them resources that they just wouldn't have access to otherwise.

 

Daniel Marino:

Yeah, well, it. It makes sense, then. So it sounds like it's patience are referred to you all and get enrolled into the program. Then you're providing some of that coordination that caregiver services billing Medicare separately. And then you get reimbursed. So you're an extended, almost an extended provider of the care that's being provided, then, through their normal physician community, if you will. Again, I mean, that sounds great, because there's no conflict of interest there.

 

Vanessa Guzman:

Correct.

 

Seth Hyman:

Yeah, that's a great way to put it.

 

Vanessa Guzman:

And it doesn't weigh on their total cost of care. If there are an ACOs participant, as Seth mentioned earlier which means there shouldn't be any hesitation right in using our services, because it just doesn't go to that to that bottom line for lack of a better term.

 

Daniel Marino:

Well, I'm sure this is new to a lot of folks, and I and I'm sure after our listeners kind of dive into it. They're going to get excited, particularly our provider community. You know. Again, I think, from an emotional standpoint, and certain from a practical standpoint. This makes a lot of sense to our caregivers and to our provider community. How can folks learn more about this? Anywhere that you would direct them, or maybe they can reach out to you all any thoughts.

 

Vanessa Guzman: Yeah, there's several ways we have informational content on our website. www.jvshealth.com just click on the GUIDE model tab on the top banner. You can also email us at info@jvshealth.com. You have the ability to submit a form or send an email with any questions but what we encourage you to do the most is talk to your provider also about it, because they may be able to also answer specific questions on what you could do now. Our program does kick off in July of 2025. So in the meantime we will work with providers across your community to make sure that there is awareness, and that we build partnerships, so that when we get to the July time frame we are ready to enroll you and your family member.

 

Daniel Marino:

Wow! Well, that's great. Well, I wish you all a lot of luck in this program. And you know again, I think this is something that is near and dear to my heart, and I'd love to have you all back, maybe in another 6 or 8 months as you started to kind of go through this a little bit, and just to hear how things are going, I know you're not kicking off until July of 2025. But wish you a lot of luck and a lot of success. I think it's going to be great.

 

Vanessa Guzman:

Thank you. We appreciate you having us.

 

Seth Hyman:

Yeah, thanks, and really appreciate the opportunity to talk about this.

 

Daniel Marino:

My pleasure, my pleasure, and I want to thank all of our listeners for tuning in. If you want to learn more about this topic, and others. Please visit luminahp.com until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners