Guiding an Improved Dementia Experience (GUIDE) Model
-
Problem: People with dementia often experience fragmented care that leads to poor health outcomes, and they typically need comprehensive caregiver support; family caregivers, who are often people with Medicare themselves, bear significant mental, physical, emotional, and financial burdens.
​
-
Solution: The GUIDE Model advances coordinated dementia care to support both people with dementia and their caregivers by providing evidence-based services including: care navigation, 24/7 access to a support line, caregiver training and education, respite services up to $2,500 annually, and connections to community resources.
​
-
Outcomes: The GUIDE Model enables people with dementia to remain safely in their homes and communities longer by preventing or delaying nursing home placement, improving quality of life for both patients and caregivers, and reducing Medicare and Medicaid expenditures.
​
-
Strategy: The GUIDE Model empowers caregivers with evidence-based tools and support while providing coordinated care management that addresses both patient and caregiver needs, ultimately preventing costlier interventions and improving health outcomes for America’s aging population.
Services
HOME BASED
PRIMARY CARE
A unique home care program that provides comprehensive primary care in the homes of
individuals with complex medical, social, and behavioral conditions for whom routine
clinic-based care is not effective or possible.
​
​
COGNITIVE ASSESSMENTS
​
Cognitive evaluation and testing for those presenting with memory or cognitive symptoms, to
help identify mild cognitive impairment and other forms of dementia.
​
​
​
MULTIBORBIDITY
Helping individuals manage multiple chronic conditions while focusing on the patient’s
priorities for health care.
​
​
​
GERIATRIC SYNDROMES
Evaluation of syndromes common to the older adult, such as delirium, depression/anxiety,
urinary incontinence, osteoporosis, and dizziness with the goal of improving patient quality of
life.
CHRONIC CARE MANAGEMENT
Comprehensive oversight and education for those with multiple chronic health conditions.
GERIATRIC PRIMARY CARE
​
Geriatricians are primary care doctors who have additional specialized training in
treating older patients with conditions unique to the aging adult.
​
​
​
​
COMPREHENSIVE GERIATRIC ASSESSMENTS
Comprehensive geriatric assessment (CGA) is defined as a multidisciplinary diagnostic
and management process that identifies medical, psychosocial, and functional
limitations of a frail older person in order to develop a coordinated plan to maximize
overall health with aging.
POLYPHARMACY
Thorough medication reconciliation and deprescribing to reduce pill burden, minimize harm,
maximize impact, and improve quality of life.
COMPREHENSIVE
PRIMARY CARE
We assist you in managing your health holistically, as a whole person, not just a collection of symptoms. We take time to get to know our patients and tailor care to individual needs, distinguished by good communication, respectful patient education, and support.
COMPREHENSIVE DEMENTIA CARE
Excellent care for those living with dementia, including Alzheimer’s disease, through
every stage of the disease process. Comprehensive dementia care includes a dementia
care plan, care coordination/navigation, and caregiver education/support.
FRAILTY AND FALL RISK
Evaluations to develop a patient-centered, multifactorial approach to management of these
syndromes common to the aging adult.
​
​
​
​
​
GOALS OF CARE
Discussions with patients and their caregivers or surrogates regarding health care
preferences and values in order to guide decision making according to patient priorities.
LQBTQ+ CARE
Providing inclusive services and care for the LGBTQ+ community.
