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A new dementia care model may contain measurement flaws that could threaten participating providers’ reimbursement and potentially affect quality of care, according to dementia care expert Zaldy Tan, MD, director of the Cedars-Sinai health system’s memory and aging program.

The Guiding an Improved Dementia Experience (GUIDE) Model, unveiled in July 2023 by the Centers for Medicare & Medicaid Services, has carved new pathways to support patients with dementia and their caregivers. Under the model, Medicare would be allowed to provide these caregivers with respite care, for instance. CMS’ discretion to pay for these services is tied to the severity of the patient’s condition. However, whether severity is an appropriate metric still remains to be seen, according to Tan. 

“The reimbursements that CMS has is tied to whether the person has mild, moderate or late- stage dementia,” he explained in an interview with McKnight’s Home Care Daily Pulse. “But I’m not sure if the disease stage equates to care intensity.”

Improper measurement system?

There is no single validated measure of dementia, Tan said, but CMS’ measurement system does little to factor in a patient’s unique care needs. A patient may have mild dementia but still require more intensive care services, he noted. Providers participating in the GUIDE Model, therefore, may not receive enough reimbursement to deliver the services that address the individualized needs of their patients.

“CMS is equating higher disease stage to needing more intensive care management. So they say that, for example, patients who enroll in the GUIDE program who are in the moderate to late stage require a home visit, which is a more intensive level of care, and the reimbursements are higher,” Tan said. “But the question is, will people with mild dementia also need a home visit? I don’t know, nobody knows. But there are people that would benefit from home visits.”

Better measurements of dementia 

Using disease stage to measure dementia is not without merit, Tan noted, but it may not provide a full picture of a patient’s specific needs. He pointed out other enterprising dementia care programs such as the University of California – San Francisco’s Memory and Aging Center Clinic, the University of California – Los Angeles’ Alzheimer’s and Dementia Care Program and Cedars-Sinai’s own C.A.R.E.S. Program, which incorporate many of the GUIDE Model’s features and could inform its development.

The C.A.R.E.S. Program, for example, includes nearly every element present in the GUIDE Model, including continuous patient monitoring and assessment, caregiver education and treatment of related conditions. However, it is different in how it measures patients’ dementia. 

Rather than using the GUIDE Model’s measurement system of mild, moderate and late stage dementia, C.A.R.E.S. uses a tool called CEDARS-6, which factors in an individual’s cognition, behaviors, environment, other conditions, social determinants of health and more. These characteristics can provide a more accurate representation of patients’ actual health needs and better guide treatment, Tan said. In a recent preliminary assessment, Cedars-Sinai’s program was found to offer “a promising approach to dementia care.”

“I think CMS is going to explore those models to see if they produce the same result or not,” Tan said. “I suspect that there’s going to be quite a bit of variability in the approach, which may be purposeful or intended by CMS so that they could compare and contrast the different models.”