Value-Based Care in Action: CMS’s GUIDE Model for Caregiver Support

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As many of our listeners know, CMS has released, over the years, numerous value-based care programs. They range from the early pioneer ACOs to the ongoing ACO REACH and some of the other ACO performance projects. There's a great program that is being released as of January 1st of 2026. It's around TEAM, which looks at the top 5 episodes, and CMS is mandating, for around 700 and 4,750 hospitals, set reimbursement around the high-volume, high-cost episodes. But there's been one program that CMS has announced and has initiated that I've been watching really close. I find it really fascinating, extremely value-added for patients and for caregivers, and that's the GUIDE model. The guide model, focuses on providing support to patients and their caregivers who have dementia and have Alzheimer's. So the CMS GUIDE program… GUIDE stands for Guiding an Improved Dementia Experience, and it's really geared towards the caregivers, and providing the right level of support to caregivers, of those that their loved ones or folks are caring for that have dementia and Alzheimer. I feel like it's just a great program, and one that from a caregiver perspective, could provide a lot of support and a lot of benefit.

Well, I'm excited to have a returning guest, Seth Hyman, who is with JVS Health, he's one of the co-founders and partners. Seth and his colleague, Vanessa Guzman, were on our program about a year and a half ago or so, and talking about GUIDE, and very excited to have him back. Seth, welcome to the program. 

Seth Hyman:  

Hey, thanks for having me back. It's great to be here. 

Daniel Marino:  

So, Seth, you've come a long way with the program. I think the first time that we had talked, you had just gotten approved as one of the administrators of the program, and you were starting to just kind of pull this together. It is a freshly launched program, and really, as of July 1st of this year, it really officially kicked off, although I know you've been doing work on this for about the last year. How's it been going? 

Seth Hyman: 

Yeah, it feels way more than a year, I'll tell you that, but it is going great. You know, we are enrolling patients now, we have our first cohort of patients in, we're serving the family members, so it's kind of surreal to be talking about it now that we are up and running and are taking care of patients, but it has been… it's been a great experience. Just kind of getting to know these families, and seeing what they're going through, and being able to help them, because, as you know, and as a lot of your listeners probably know. It's a disease that not only affects the patients, it really also is terrible for the families, and it really is so isolating and difficult for them. So, to be able to provide some level of support for them is really been rewarding for us, and we're very excited to see where, you know, where we are right now. 

Daniel Marino:  

Oh, absolutely, and I agree with you. I think the support to be able to provide to caregivers of patients who have dementia, you know, this just has a tremendous amount of value. For our listeners, why don't you take a step back. Talk a little bit about just the aspects of the program. Give a quick overview, if you can. 

Seth Hyman:  

Yeah, absolutely. So, there's two main components of the program. The first is a true care navigation, where we will assign each patient, each family caregiver, a navigator, is what we call them. And that person will think of them as a trusted advisor, as a real resource for the family. They're there to help them coordinate all the different benefits, to help guide them, no pun intended, through this journey, and really, as I said, just be a trusted advisor and a shoulder to lean on. So, we'll do things like coordinate doctor's visits, we will have trainings that we could schedule live and recorded for the families to help them with basic housekeeping needs and things like that. So, really just there to connect them to all the available resources that they… that they have. The second component of the program is the respite. So, through this program, CMS has, for the first time, allocated money to us to distribute on behalf of these families for one of three areas of respite. The first is a in-home situation where you could we will find someone to bring into the home as a home attendant. They could do… or if they have someone that they're already working with, we could, work with that individual. So, the home… in-home respite is the most popular that we've been seeing. They also have, adult day centers, so if you want to take your loved one somewhere for the day where they could participate in different sort of programs at a senior center or something like that, we have that available. And then the last is a short-term stay in a memory care facility. So, you know, if you have to go out of town, or anything that you're unable to take care of your loved one for a couple of days, this is an opportunity for you to bring them there and have them stay overnight. So, those are the three areas of respite that they are able to choose from.

Daniel Marino:  

Well, and the rest of it's just so much value for some of these caregivers, right? Because, you know, a lot of times, and historically, they're on their own. They may get help from their family members, but there's really no outside support, and as well, there's no funding for this. So I would imagine that the level of respite or the level of support, would be dependent on, let's say, how advanced the patient is, or their loved one is with dementia and or Alzheimer's. How do you go about determining that? 

Seth Hyman:  

Yeah, so the way that the program works is that, based off of our intake process, we have a series of questionnaires that we have to administer to the patient before we can admit them. They get placed in a tier. Just kind of as you alluded to, it's a low, moderate, and complex tier based on the severity of the Alzheimer's and the progression of the disease. Now, that is… we have to do a reassessment every year on these patients, so just because you start in one doesn't mean that you might not progress as the disease progresses, but anyway, based off the low, moderate, and complex tiers, that determines whether or not the patient is eligible for the respite. So, the folks that are in the moderate to complex tier are the only ones that qualify for the respite. And then each of those patients is allocated nationally $2,500 per year. So, again, we're not going to cover the entire bit of respite, but it is definitely something to get started with the process, and it is sometimes very beneficial just to get started with some amount of money. 

Daniel Marino:  

Yeah, yeah, absolutely. And, you know, I think, I've been watching very closely what CMS is doing, what Dr. Oz is doing, and, you know, he's pulled back on some of the programs, but this is one that still, has pretty much the attention, from a bipartisan perspective, frankly, in continuing to provide this level of support. You had mentioned the financial piece and some of the reimbursement that comes in. Are you able to see a difference between, maybe for some of these more complicated, more advanced patients, they frankly may need a little bit more support. Is that $2,500 that you had mentioned, are you finding it enough to cover? Is it just the tip of the iceberg when it comes into that level of support? And, you know, how can you possibly, or is there ways to maybe put in exceptions for additional funding. 

Seth Hyman:  

Yeah, right now, that's the total amount of money that we get for each patient for respite. I think, you know, there's… they've already kind of upped the rates a little bit, so I think as time goes on, that might go… we're hopefully hopeful that that might increase a little bit, but, you know, CMS has been very responsive to our, feedback, and they have made some other changes, so we'll see. Listen, as I said, it's definitely not enough to cover everything, but every little bit does count. It does count. And kind of, you know, from personal experience, you know, a family member of ours was struggling as a caregiver, and didn't really want t Didn't really want to give in to, you know, bring someone into the home. They were just like, you know, I'm not doing it, I'm not spending the money, I'm not spending the money, and really delayed getting that help for a long time. So, I know from our experience that we would have had this money to say, hey, listen, let's just try it out. It's free, it doesn't cost you anything. Let's get the… let's get you in the door, let's get started. I think it would have made a big difference. I think it would have, you know, really made him more receptive to doing it, so that's something that we are seeing, that, you know, if you do have, you know, a spouse that's kind of on the fence about it, this is a good way to get started. But, as you know, every little bit does have, does… 

Daniel Marino:  

Good way to get started, no doubt about that, and just to get the caregivers and really everybody familiar with this. If you're just joining us, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I am here today talking to Seth Hyman, who is administering one of the GUIDE model programs as part of JVS Health. And Seth, let's dive into one other area there, and that's kind of the alignment with the primary care physician or geriatric providers, specialty providers. They're the ones, historically, and currently and historically, have really been involved directly in the care of these patients, and have provided that level of support, you know, to the caregivers and so forth. How are you interacting with the primary care physicians? I would assume they're the ones that are for the most part, really providing a number of the referrals for you into the program. 

Seth Hyman:  

Yeah, no, it's been… it's been great. We have a number of primary care partners that we're working with, and geriatricians, and neurologists, and social workers as well, that we're working with that are referring directly to us. We, right off the bat, tell them that, you know, this is a social service program, we're not practicing medicine, we're not, changing medications or prescribing anything, ordering tests or changing any regimens. We're here to help them, we're an extension of the program, and a lot… and the feedback has been tremendous. Because a lot of primary care doctors don't have the resources or the time to really engage in some of these programs, and they don't know where to turn, so we were able to come in and say, hey, Send them to us, we'll take care of them. We'll be an extension of your practice, we'll be an extension of you as a social worker. So they've been just tremendous. As soon as we tell them, they're like, how do we… how do we send more? 

Daniel Marino:  

I would think these primary care physicians have to love this, right? Because this is an avenue where they can begin to offer some support for these patients and the caregivers. What's been the collaboration mechanism, though? Do you… are you… you know, because I would think that through some of these discussions, I mean, you're right there with the caregiver and, to a certain extent, with the patient. If you… are you… if you identify some challenges with the patients, or maybe with the home environment, that sort of thing, what's the level of collaboration that your team is having with the primary cares? 

Seth Hyman: 

So, yeah, it's a great question. That's really up to the individual provider, how involved they want to be, and what their workflow is, and what their, you know, desire to be involved is. So we share our notes, obviously, all of our care plans directly with the providers on a monthly basis and let them know if there's any escalations, right? You know, you know, any rapid deteriorations that our care navigators are noticing, we quickly communicate that to the PCP.  As I said, though, it really does depend. Some want to be more… way more involved, and would actually like to have monthly care conferences, which we're happy to do. But others that don't really have the time. You know, as you know, primary care providers are already way too busy and don't have enough time as it is, so that might not be feasible. We could just, you know, fax or send the care plans however they want to the offices, and we're always available if they need to reach us. So it's very, you know, we work very closely with these PCPs, and t's a real collaboration. 

Daniel Marino:  

Yeah, and I mean, that's the benefit, right? Because you're right there on the ground floor, especially if you're starting to see some changes with the patient, or maybe get out ahead of some potential challenges that would occur, and oftentimes what we see is it's all on the shoulders of the caregivers, and caregivers don't often know what to do, they can't get ahold of their primary care physician, so what do they do? They bring the patient to the emergency room. 

Seth Hyman:  

Exactly, and that's what we're trying to… well, at least the goal of the program one from CMS's perspective, is really to kind of alleviate that and keep these folks in their home as much as possible. Because, as you said, your first reaction is take them to the emergency room. If you're burnt out, don't know what to do, a lot of times, take them to the emergency room. We actually have a 24-hour hotline, so if, you know… again, we're not practicing medicine, so if there's a medical emergency, call 911, of course. But having that resource as someone, you know, you don't know what to do, you're feeling stressed out, having someone to call and talk to, you'd be surprised how far that goes, and we've already seen it a couple of times. 

Daniel Marino:  

Well, that is… that's fantastic, no doubt, especially having that hotline just being that level of support. You know, as you've… as you've been launching the program July 1st, and, you know, again, we're probably a good couple months into the program now. What have been some of the challenges that you've seen with the program? 

Seth Hyman:  

That's a good question. I would say the… for us, number one is getting the… developing the relationships with the respite providers. Really finding that, because finding those relationships, and then building on those relationships, and making sure that we have reliable coverage in all the areas that we go into, I would say that would be our biggest challenge because, you know, when we go into a new area, we want to make sure that we have that… that built out. So I would say finding the respite is probably our number… number one challenge. 

Daniel Marino:  

Yeah, just to kind of connect with folks. So, are most of your patients… I know you, you know, your organization is really based in the Northeast and then around the New York area. Is that kind of your primary catchment area, or are you, expanding beyond that, even across the country in some of the other markets? 

Seth Hyman:  

Yeah, right now, I'd say we are focused on the tri-state area up here in New York, New Jersey, Connecticut areas, but we are definitely exploring other areas. Like I said, we don't want to go into a new market until we're able to really make sure that we could serve those folks. But we do have partnerships with some organizations, like in Colorado, where we're partnering with a primary care provider in that state, and we could actually sign a contract with them where they could do the comprehensive assessments for us. So, definitely open to… always open to those types of partnerships where we can work with an organization, let's say anywhere in the country, that has a good network of patients and wants to get involved. They can contact us, we'll kind of arrange where they could do those comprehensive assessments for us, and kind of act as the front door to getting these folks into… into the GUIDE model. 

Daniel Marino:  

Yeah, that's great. Well, and like I said, the partnership is really what's gonna… it's gonna be key here. I mean, it really does take a village as you start to think about providing that level of care. 

Seth Hyman:  

Absolutely. 

Daniel Marino:  

Any, I was interested in the stories. Any positive stories, any, interesting lessons learned that's come out of, the last couple of months? 

Seth Hyman:

Boy, there, there, there's so many, just, like I said, I think just having… Being able to provide that support to these, to these patients. You know, we get it all the time, where we hear. I just need someone to talk to. You know, a lot of times we would think, oh, you know, all these benefits that we have are great, but sometimes they just need someone to talk to we all… we all really, sympathize. You know, we could all sympathize, but, you know, for us, it's personal. We've had a personal story with, with dementia, so just being able to, 

Daniel Marino:  

Yeah. 

Seth Hyman:  

To be able to be that shoulder to lean on, and it really is helpful. 

Daniel Marino:  

Yeah, just to provide that level of support. 

Daniel Marino:  

You know, one of the things that… I had a personal experience as well, too. A very close friend of mine, had developed Alzheimer's, and he was in his mid-80s. The wife was taking care of it, and she was clearly overwhelmed. One of the… as we had offered, I mean, this was before the GUIDE model, obviously, but before, we had offered a lot of support and tried to get some social worker in there, and even to the point where we paid for some concierge-type care management. One of the things that we found was just getting past… just getting the caregiver or getting his wife comfortable with having somebody come in, they're resistant from our experience. you know, and building that trust was something that it took a while to overcome. How have you been working through that? I would assume you're sort of having those same challenges. 

Seth Hyman:  

Yeah, I think the way that we kind of address this is that we insist and we make sure that all of our care navigators it's a one-on-one relationship, right? So you're not getting a different person every time. So they… we spent a… we spent a lot of time when we were building this program, ensuring that our care navigators are people that can form those bonds and those relationships. So when you pick up the phone, you know you're who you're getting, right? You know you're getting Lily, or Stacy, or whomever, that's going to be your person. It's not going to constantly be changing someone that doesn't know your situation. Because a lot of times what happens is these folks get passed around from one organization to the next, and they just don't know… they just feel… they feel kind of, like, cheap. So, these are real relationships. We're trying to develop these bonds that are going to last for years, right? And they're going to be here to navigate them through this… through this journey. 

Daniel Marino:  

Well, and I give you a lot of credit for that. Building that personal relationship, that's really where the comfort level starts, right? 

Seth Hyman:  

Yeah, yeah, absolutely. 

Daniel Marino: 

And then they know that, hey, there's somebody there that they can call. Given that this is kind of an introductory program, CMS is sort of watching it, and you know, these types of programs, always beholden to, Congress and, and budget passages and requirements and so forth. Where do you think the GUIDE model's going to go? Do you think this is something that's going to continue to evolve? And clearly, I think it has a tremendous amount of value. Where do you think it's going to go? 

Seth Hyman:  

Yeah, I think, well, it's an 8-year program, so it's been re-upped for 8 years. It's, as you mentioned, bipartisan. It was initially a Democratic initiative that was introduced by a Democratic administration, but then survived into the next administration. They did a deep dive, and they said, this looks great, we want to continue. So we're fully committed for the next 8 years. I'm not… I don't pretend to know what's going on in Washington, or pretend to want to know we can't control that. All we know is that we're good to go for these next 8 years, and I do think that the people see the benefit here. So, it's a need, it's such a need, and it's just such a no-brainer once you kind of lay it out there, so as far as we're concerned, I think it's going to continue to grow. I don't know if they're going to expand the program or not, add more participants. That could definitely be something that happens, especially in certain parts of the country. We welcome that, you know, we want to just take care of as many patients as possible, so that's… that's where we're at, where all systems go for the next 8 years. 

Daniel Marino:  

That's great. Well, it's great to hear that it is an 8-year program, because that does give you time to invest in the program, to really track the outcomes, and, you know, as we talked about, you know, continue to provide that value to the caregivers and to the patients. So, we have a lot of, providers, a lot of, physicians, healthcare leaders that, that tune into the program from, within Value-Based Care Insights. If folks are interested in learning more, or even referring to you in the program, how do they go about doing that? 

Seth Hyman: 

Absolutely. I would just think I would refer everyone to our website, www.jvshealth.com. And right there on the front page, there's a providers, there's a big button that says, refer here, that you could click on. Patients can also self-refer So that's something I definitely want to stress here. It does not have to be a primary care doctor or any type of doctor referring this program. Patients can come to our website, go right there on our… and click, self-refer. And it'll bring them right to our page that they could go ahead and fill out the forms. We do everything online, so all these forms can be done online. Then we do just a quick 20-minute visit, or 10-minute visit with one of our nurses. That will kind of get the process going, and, you know, hopefully within 3 to 4 weeks, they'll be approved by CMS. So we try to streamline it, make it as simple, as easy as possible. They could also email us at info@jvshealth.com. 

Daniel Marino:  

That's great. You know, the nice thing about that is not only the physicians could refer, but patients could self-refer. 

Seth Hyman:  

Absolutely. 

Daniel Marino:  

Which is unusual in a program, typically. A lot of times, if there's dollar attached to it, you'd have to have a referral from the physicians, but that, boy, that's a nice feature. 

Seth Hyman:  

Yeah, once we… we will… we actually go and reach out to the physicians. We'll need to get a medical record from, you know, a copy of the medical record, the diagnosis, but we handle all that for the patient, so they don't have to go worry about that. So, you know, we're not cutting the provider out of the… out of it, we're just kind of taking it off their plate and making it, you know, streamlining it, making it easier for them. 

Daniel Marino:  

Well, making it easier for the physicians, which, again, makes it, you know, the streamlines that process all the way along, but, you know, I would think then there has to be some outreach to the physician, like you said, just to get some of the background and just some general information, so when the nurses do call and evaluate, you know, they have something to go on, which, frankly, helps the process all the way along. 

Seth Hyman:  

Absolutely, yes, absolutely. 

Daniel Marino:  

Well, Seth, thanks for coming on. Again, this is a program that I've been watching for quite some time. I think we all know somebody who, either within our family or friends, who've had Alzheimer's or dementia, and we see the struggles, right? So this program, I think, has a lot of value. Can you give your email address, or maybe the website, one more time? 

Seth Hyman:  

Yeah, absolutely. It's www.jvshealth.com. 

Seth Hyman:  

Also, email me, Seth, S-E-T-H, at jvshealth.com. I'm always available. 

Daniel Marino:  

Great. Well, thanks again, Seth. Again, I'd love to have you back sometime down the road. Of course. Maybe some of your outcomes, you know, as you're starting to see this. I'm sure you're tracking quite a few. 

Seth Hyman:  

Yeah, absolutely. Well, I appreciate it. Thanks for having me. It's been great.  

Daniel Marino:  

Thanks, I appreciate it, Seth, thank you. And to our listeners, if you're interested in, again, finding out a little bit more about the GUIDE model, or any of our topics that we discuss on Value-Based Care Insights. Don't hesitate to, join luminaHP.com/insights, or contact me directly at dmarino@luminaHP.com. Until our next insights, this is Daniel Marino, bringing you 30 minutes 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