A dementia care model still needs a local route to help

What we found in the news

On July 31, 2023, the Centers for Medicare & Medicaid Services announced its Guiding an Improved Dementia Experience model, or GUIDE (opens in a new tab). CMS described a model intended to:

“help people remain in their homes and communities”

— Centers for Medicare & Medicaid Services, July 2023

The announcement brought together care navigation, caregiver education and support, and respite. As of this November reference point, the voluntary model was planned to begin July 1, 2024. It was an upcoming test involving participating organizations and eligible people with Medicare, not a service already available to every family. Its ambitions were not evidence of achieved results.

Why this matters to us

A national announcement can make a possibility visible. Someone still has to turn that possibility into an understandable local offer.

Imagine a community program manager preparing for a conversation with a health-system partner. Both want people living with dementia to find useful support. The manager has a day program, a local transport contact, and colleagues who know the neighborhood. The health system has clinical responsibilities and a different set of arrangements.

A family should not need to understand the two organizations' structures to discover whether any of that help is available. At genus, we are interested in the practical connections that let people ask an ordinary question and reach someone equipped to answer.

Explain the offer before sharing the headline

For our illustrative manager, the first task is to separate what is available now from what is being explored. A planned partnership, an application, and a confirmed service are different things.

Before mentioning a program to families, agree who can explain its eligibility and availability. Prepare a clear route for questions that colleagues cannot answer. If participation or funding is undecided, say so. A hopeful conversation can still be useful when its limits are clear.

Keep that distinction in newsletters, reception notes, and community meetings. Readers may remember the possibility of support more readily than a qualification placed several paragraphs later. Put the important conditions beside the offer, where someone is deciding what to do.

Build the connection around a person's priorities

Ask what the person living with dementia wants to keep doing and what support they would welcome. Their answer might concern a familiar outing, time at home, or seeing particular people. A caregiver may have a different but related concern about making the week manageable.

Bring those priorities into the planning conversation with permission. They help partners examine whether a proposed service fits the person's life. An available activity at an inconvenient time may create another problem for the household.

In our example, a navigator could help establish which organization will answer a transport question and who will confirm a first visit. That work needs agreed responsibilities and a way to check the answer. Giving someone a list of organizations leaves them to discover the connections for themselves.

Make the handover useful to the receiving team

Agree what the next team needs to know, how information can be shared appropriately, and who will check that a request reached its destination. Send only what is needed through the approved process.

Include the person's own preferences where relevant, alongside the practical details. A note that someone wants a quiet introduction may be more useful to a welcoming colleague than a general description of their circumstances.

Then make the next contact clear to the person and their chosen supporter. They should know whether they are waiting for an assessment, a telephone call, or confirmation of a place. If an arrangement cannot proceed, offer an accurate explanation and discuss available alternatives without implying they are equivalent.

What this means for the people you serve

A new model can create interest and questions well before a service begins. People deserve explanations they can use without being made responsible for the uncertainty between organizations. Involve them in defining what useful support would look like, and make room for someone to decline an option that does not fit.

The genus connection

Today, configured genus care apps and care walls can provide a place for program resources, conversations, events, and updates for the intended audience. Invitations and permissions shape who can see and use those features.

That can support a clearer connection between reviewed information and the people a program serves. It does not establish GUIDE participation, determine eligibility, or supply the staffing behind care navigation. Those arrangements belong to the participating organizations and the people involved. We would begin by agreeing the service and its responsibilities, then confirm how the available tools could support them.

One question for your next partnership meeting

Before we point someone toward a new program, can we explain who it serves, what happens next, and who will help if the route becomes unclear?