On July 8, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced a new pilot program, the Guiding an Improved Dementia Experience (GUIDE) Model, which emphasizes providing support and services to both patients and caregivers and aims to effectively address the challenges posed by dementia.
Across the country, 390 providers, including Grady Health System, representing a wide range of healthcare providers, including large academic medical centers, small group practices, community-based organizations, health systems, hospice agencies, and other practices, will participate in this pilot program and provide coordinated care and support for people living with dementia and their unpaid caregivers.
Gabriela Cohen, MD, and her Emory at Grady Geriatric team will lead the implementation of the GUIDE model at Grady. The new program called GUIDE at Grady, will be based on one of the established comprehensive dementia care models as mentioned above.
After evaluating the available GUIDE model programs, including Emory’s Integrated Memory Care Clinic, the team reviewed all available models for one that would best fit the unique needs of Grady’s diverse patient population. Based on Grady’s patient needs, the team looked for a model that utilized community health workers, social workers who make multiple home visits, and a coordinated co-management care structure with the patient’s existing primary care physician in order to decrease the fragmentation of care for Grady’s patient population who typically have high health utilization or health transitions.
After much analysis, research, and careful consideration, the team chose to follow the Aging Brain Care Program (ABC) at Indiana University’s Department of Medicine, a program created at a similar safety-net hospital that includes all these aspects of care to best address the many and at times complicated, needs of Grady’s patients. In this model, all interventions will be done in collaboration with the primary care provider—the ABC model does not assume the care of the patient but rather brings additional resources to the table for the provider. The GUIDE at Grady program will use the model, tools, and assessments developed by the ABC team at Indiana University and will incorporate patient evaluation and continuity care provided by dementia expert providers to the GUIDE at Grady Model. The program will run for a total of eight years, beginning with a one-year implementation period, and will start recruiting patients in July 2025.
To learn more about the new GUIDE at Grady program, read the Atlanta Journal Constitution’s July 9 article.
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