GUIDE MODEL OF CARE
Guiding an Improved Dementia Experience
GUIDE (Guiding an Improved Dementia Experience) is a program offering ongoing support focused on improving the quality of life of individuals living alone with mild to severe dementia or living with their caregivers. Eligibility for the program requires the individual with the cognitive impairment be on Medicare (Part A & B).
Program Benefits
-
Access to long term care resources
-
Improved health outcomes
-
Reduced caregiver burden
Meet Your GUIDE Care Team
Suresh Jaiswal, M.D.
GUIDE Medical Director
Kelly Zolman​
GUIDE Adult Gerontology
Nurse Practitioner
Amber Sizelove
GUIDE Care Navigator
ABC Community-GUIDE Certified
GUIDE Services
The Nurse Practitioner will provide:​
-
An annual assessment
-
Dementia symptom management
-
Collaboration with the Primary Care Provider and Specialists
The Care Navigator will provide:​
-
Care coordination
-
Person centered care planning
-
Caregiver education and support
.png)
Frequently Asked Questions
Does an individual need a caregiver to participate? No, if the individual meets the requirements detailed above, they do not have to have a caregiver to participate.
Does an individual need a formal referral for the GUIDE program? No, you do not need a formal referral from a medical professional to be referred for the GUIDE program. You may refer yourself or someone you know to the program or referrals may come from healthcare professionals, community agencies, community members, etc.
What happens during the GUIDE enrollment process? 1. The AIHS GUIDE program receives a potential referral on an individual (this can come from a healthcare provider, a caregiver or family member, community organization, or the individual can self-refer). Referral from a healthcare provider or a community organization should use the GUIDE referral form. This can be completed electronically and emailed to the GUIDE team. To request the referral form, contact the GUIDE team at GUIDE@agingihs.org. If the referral is from an individual, caregiver, or family member they can request the referral form at GUIDE@agingihs.org or call the GUIDE team at 260-745-1200 ext. 258 to speak with the GUIDE Nurse Practitioner who will assist them in completing the referral form over the phone. 2. Once a referral is received by AIHS, the GUIDE team will do an initial screening to ensure the individual meets the basic requirements of GUIDE. 3. If the individual meets screening criteria, the GUIDE team will contact them to set up an initial assessment. This will include a clinical assessment by the Nurse Practitioner and the GUIDE Care Navigator. This visit may happen at the GUIDE clinic or in the individual’s home. 4. The AIHS GUIDE team will submit all the required assessment data electronically to CMS for review and final approval for the individual to be assigned to the AIHS GUIDE program. CMS generally takes 15 business days to complete this review. 5. If the Individual is assigned to the AIHS GUIDE program the next step will be an in-home follow-up visit by the Care Navigator to review home safety needs, assist the individual and caregiver to connect to needed community services and provide education to the caregiver about dementia and supporting an individual with dementia at home. This support will continue monthly for most participants and their caregivers based on their needs. The Nurse Practitioner will see the individual as needed after the first visit and will complete an annual assessment to determine ongoing eligibility for the GUIDE program. 6. If an individual is not approved by CMS for participation in the GUIDE program they will be referred to the AIHS Aging and Disability Resource Center (ADRC) for other support as needed. 7. All individuals who complete the GUIDE assessment process will receive a letter following the CMS review to inform them of the CMS decision about assignment to the GUIDE program.
Can we have other services while enrolled in GUIDE? You cannot be in a long-term care facility, utilizing your hospice benefit, or utilizing the PACE program. You can receive other services such as nutrition or transportation support, Medicaid waiver services, etc., if you are eligible.
What is the cost for the GUIDE program? The GUIDE program is fully covered by traditional Medicare (Parts A & B).
Will the GUIDE program replace my Primary Care Provider? No, if you have an established relationship with a physician, the GUIDE program can collaborate with your them. The GUIDE program can focus specifically on dementia management and keep your physician updated on the services provided by the GUIDE program. If a participant comes into the GUIDE program without a physician already selected, they can also elect the program’s Nurse Practitioner (NP) to serve as their physician. In this case the GUIDE NP would manage their dementia care as well as all other medical care under Medicare. In this case the GUIDE related service would continue to be covered by fully Medicare, however other medical services may have a co-pay under your Medicare plan. Discuss this with the GUIDE staff if you have questions.
GUIDE is provided by Aging & In-Home Services of Northeast Indiana and funded through the Centers for Medicare and Medicaid Services (CMS) for individuals who have fee for service Medicare. This program is currently not available to individuals enrolled in Medicare Part C (Medicare Advantage Plans), PACE or receiving Hospice.