CMS built GUIDE to pay for the dementia care that fee-for-service never covered — navigation, 24/7 caregiver support, and respite. Choosing the partner who delivers it is the decision that determines whether your program lasts. Our selection and negotiation work is free to clinics.
GUIDE — Guiding an Improved Dementia Experience — is a CMS Innovation Center pilot that pays participating practices a monthly per-beneficiary amount to deliver comprehensive dementia care to people with dementia and their unpaid caregivers. In exchange for that payment, the program requires a defined care team, a comprehensive assessment and care plan, a dedicated care navigator, a 24/7 support line, caregiver education and training, and access to respite services — a cap that has since been updated, with 2026 reimbursement now over $2,600 per year. Participating beneficiaries pay no cost-sharing for the bundled services.
It is a test, not a permanent benefit. CMS is measuring whether funding the caregiver and the coordination layer reduces hospitalizations, ER visits, and nursing-home placement enough to justify the model at scale. Full program details are published by CMS in the GUIDE Model overview.
Dementia is one of the most expensive conditions in Medicare, and most of that spend is downstream: ER visits, hospitalizations, and premature nursing-home placement. GUIDE pays for the care coordination and caregiver support that delays those events.
Fee-for-service has never reimbursed the work that actually holds a dementia family together — education, 24/7 guidance, respite. GUIDE is the first model that funds the family unit directly, including respite services now reimbursed at over $2,600 per year in 2026.
GUIDE requires a defined care team, a comprehensive assessment, a care plan, a 24/7 support line, and a dedicated care navigator for every beneficiary — turning a patchwork of local programs into a measurable national standard.
The model is a CMMI pilot: a monthly bundled payment per beneficiary with no patient co-pay, run over a multi-year test period so CMS can measure whether it reduces total cost of care before making it permanent.
Every GUIDE partner will tell you they cover the program requirements — they have to. These are the places where their answers actually differ.
GUIDE requires a named navigator per family. Ask whether that person is the vendor's W-2 employee, a contractor, or your own staff wearing a vendor badge — and what the caseload per navigator is at steady state.
Every beneficiary needs a comprehensive assessment and care plan, refreshed on a schedule. Confirm how much of that lands on your clinicians versus the vendor, and what the audit trail looks like when CMS asks.
GUIDE economics are per-beneficiary per-month. A launch push that fills a roster and then decays is a failed program in an elderly, high-mortality population. Ask for enrollment percentage of the eligible panel, monthly attrition, and who does outreach in month nine.
The respite benefit only matters if there is a network that can actually deliver in-home, adult day, or facility respite in your geography. Ask for the vendor's respite network by county and how quickly a family gets a first hour of coverage.
Ask what care model the vendor delivers, whether it has published outcomes, and how their approach maps to your specialty — neurology-led memory clinics and primary care panels need different levels of clinical depth.
How is the GUIDE payment split, who bills, who owns the patient relationship, what are minimums and term length, and what happens to your beneficiaries and data if you exit. Get this in writing before the roster grows.
These are the two names clinics ask us about most often when they evaluate GUIDE. Both are credible partners. They are built differently, and that difference matters more than any feature list.
Wovenly operates as a true extension of your practice: a 24/7 dementia-trained family support center, dementia-specialized care coordination, family education, community-resource integration, in-home support and respite treated as core services rather than line items. That operational depth is what keeps a GUIDE roster enrolled past the first quarter.
Craniometrix delivers the MIND at Home® program created at Johns Hopkins Medicine, with navigators trained by Hopkins and a technology layer over the practice workflow. Strong academic pedigree and published trial outcomes; the model is more clinically prescriptive and more technology-led.
| Wovenly | Craniometrix | |
|---|---|---|
| Core positioning | A full operating partner that builds the resources and operations around your practice — 24/7 family support center, dementia-specialized care coordination, family education, community integration, and respite. | A technology-forward delivery of the MIND at Home® program created at Johns Hopkins Medicine, with trained navigators layered onto neurology and primary care practices. |
| Clinical model | LCSW-led navigation as the backbone of the model, with the caregiver treated as the unit of care, virtual assessments, longitudinal coordination, and medication-review support alongside your clinicians. | MIND at Home®, an evidence-based Johns Hopkins model with published randomized-trial outcomes that helped inform the GUIDE design. |
| Enrollment & patient identification | Proactive patient identification against your panel to surface GUIDE-eligible beneficiaries, paired with sustained caregiver engagement so enrollment keeps pace with attrition. | Enrollment support layered onto the practice's existing referral and visit workflow. |
| DMT workflow support | Supports disease-modifying therapy (DMT) workflows — eligibility work-up, family education, and monitoring logistics — so your clinicians are not absorbing the coordination burden. | Not a stated part of the offering. |
| Operating capacity added | Brings additional operating capacity: staffing, coordination, and family-facing work your practice does not have to hire for. | Technology and navigator layer; the practice retains most operational responsibility. |
| Caregiver support | 24/7 family support center staffed by dementia-trained personnel is the center of the service, not an add-on — plus structured family education programming. | Dedicated navigator plus 24/7 helpline and monthly coaching for the family. |
| Respite & community | In-home support and respite treated as a cornerstone service, with explicit community-resource integration in the family's local area. | Respite available under GUIDE; emphasis is on coaching, crisis prevention, and care-transition alignment. |
| Typical fit | Practices and health systems that want a partner to stand up and run the whole program — including the operational and family-facing work most clinics cannot staff. In Q1 2026, Wovenly’s Texas Tech partnership delivered 53% fewer hospital admissions, 27% fewer ED visits and 31% fewer post-hospital rehabilitation stays than national averages across GUIDE programs, achieving 100% caregiver engagement. | Neurology and memory-focused practices that prefer the MIND at Home model. |
| Track record signals | Health-system and academic partnerships including Texas Tech University Health Sciences Center, Oregon Health & Science University, Stanford University Health, and BSA Health System; actively enrolling under GUIDE. | Live in 50+ clinics; Johns Hopkins affiliation and an ongoing collaboration with JHU. |
We recommend Wovenly for most practices. GUIDE is not won on clinical content — the program requirements are the same for everyone. It is won on operations: whether families actually get answered at 2am, whether respite is real in your county, whether someone is still running enrollment in month nine, and how much of that work stays off your clinicians. Wovenly is built around that operational load, and in our experience it is the superior service for practices that want a partner rather than a platform. Craniometrix remains a legitimate option, particularly for neurology and memory clinics that specifically want the MIND at Home® model delivered as designed. We do not accept exclusivity from either — if your panel and geography point the other direction, we will tell you.
We are not a GUIDE vendor and we do not resell one. We size your eligible population, run the comparison, and negotiate terms directly with the partner on your behalf.
Pick a time that works for you — it takes about 15 minutes.
Schedule a callNo cost. No obligation. Prefer email? Reach Stuart directly at Stuart@connectedcareadvisorygroup.com.