On July 1, 2024, the Facilities for Medicare & Medicaid Providers (CMS) Innovation Heart launched the Guiding an Improved Dementia Expertise (GUIDE) Mannequin, with 330 collaborating organizations presently constructing dementia care applications serving a whole lot of 1000’s of individuals with Medicare nationwide. On the latest fall assembly of the Nationwide Affiliation of ACOs (NAACOS), Bluestone ACO’s Nate Hunkins, M.P.H., shared some early classes realized in this system.
The GUIDE Mannequin is slated to run for eight years and is without doubt one of the first Innovation Heart care fashions to give attention to longitudinal, condition-specific complete care, a key ingredient of the Innovation Heart’s 2022 Specialty Technique. In the present day, practically 7 million Individuals reside with Alzheimer’s illness or one other type of dementia, and, by 2060 the variety of Individuals dwelling with dementia is predicted to double to 14 million.
Eighty-nine organizations started their efficiency interval within the different fee mannequin on July 1, 2024, whereas 241 organizations had a one-year pre-implementation interval beginning July 1, 2024, and commenced their efficiency on July 1, 2025.
Beneath the mannequin, individuals are assigning folks with dementia and their caregivers to a care navigator who helps them entry GUIDE companies and helps and non-GUIDE companies and helps together with scientific companies and non-clinical companies similar to meals and transportation by community-based organizations. Mannequin individuals are additionally serving to caregivers entry respite companies, which allow them to take non permanent breaks from their caregiving tasks.
GUIDE individuals signify a variety of suppliers, together with massive educational medical facilities, small group practices, community-based organizations, well being methods, hospice businesses, and different practices.
Talking on a NAACOS panel, Hunkins first gave some background about Bluestone and why GUIDE made a lot sense for them to take part in. “At Bluestone, we imagine sufferers with advanced power situations deserve superior major care,” he stated. “We offer major care and give attention to assisted dwelling communities. Bluestone actually is a distinct segment supplier within the sense that we’re not in expert nursing amenities. We do some little bit of impartial dwelling, however we’re primarily an assisted dwelling major care group throughout three markets — Minnesota, Florida and Wisconsin.”
Bluestone ACO saved Medicare $33.6 million in 2024 as a part of the Medicare Shared Financial savings Program (MSSP) by its care for five,772 Medicare beneficiaries who reside at assisted dwelling, reminiscence care, and group house communities. Bluestone ACO will develop its mannequin in 2026 in partnership with Herself Well being, an organization offering complete major care to girls as they age and mature.
The common age of Bluestone’s inhabitants is 82, with a median of seven power situations. Roughly 65% of its sufferers are eligible for GUIDE.
“Whether or not or to not enter GUIDE felt like a reasonably simple resolution, conceptually, as a result of this can be a inhabitants that we serve at scale primarily,” he stated. “We have now care coordination. We name it advanced care administration. We have got behavioral well being specialists who’re integrating inside our major care. So once we checked out GUIDE, the true query was that we have a lot ancillary help inside our superior major care mannequin, how do we actually slot in GUIDE in order that we’re not overlapping companies and actually contributing to higher prices inside the healthcare system? We want to have the ability to ship this effectively. We have now not figured that out completely, however that was the premise that we understood from the start — that this has to combine with our mannequin, not simply be additive when it comes to value and further companies with out true worth to the sufferers.”
When Bluestone execs checked out which GUIDE companies it’s not providing inside its superior major care mannequin, they realized it was having a devoted care navigation for all the eligible residents and caregivers.
“Beforehand, we weren’t doing a full wants evaluation, together with the SDOH part for our sufferers with dementia, so we did see that as a possibility to leverage that data to offer extra complete look after our sufferers,” Hunkins stated. “We noticed that the dementia care navigator might truly take a few of this superior care planning from our major care suppliers and assist tee up a few of that dialog and actually work with the caregiver, together with the affected person in having that dialog.”
Hunkins stated one other piece of that is being extra delicate to alter in situations. As an ACO, they wish to be certain that they’re stopping hospitalizations and the transition to long-term care. “We wanted to ensure that our dementia care navigators have been including worth round transitions of care. How are we guaranteeing that we’re looping in the complete group to make the best resolution on the best degree of look after the sufferers?”
Even previous to the GUIDE mannequin, Hunkins stated, they estimated about 20% to 25% of their ED visits have been avoidable. “What we have finished is figure on how we intervene upstream. Additionally, if our sufferers enter the ED, how can we intervene on the ED so that does not result in an admission. Many individuals within the dementia inhabitants cannot advocate for themselves. They cannot truly articulate what their needs are. We see that as our accountability as major care and a GUIDE participant — to ensure that we’re advocating alongside the caregiver, if they’ve one, to make sure they get the best degree of care inside the hospital setting, as a result of the default for somebody who cannot articulate their wants is to get them admitted,” he defined. “We’re attempting to ensure that we have now documentation of what these affected person needs are, after which have care navigators, in collaboration with our advanced care managers, intervening inside that ED.”
Primarily, Bluestone noticed GUIDE as a lever for value-based care and general ACO enchancment. “For us, there actually wasn’t a query of whether or not we have been going to do it, nevertheless it was a matter of how we are able to guarantee this is not going to be additive and result in higher prices inside our ACO,” Hunkins stated. “We do assume that avoiding hospitalizations and doing extra proactive, superior care planning are the levers to have the ability to create the offset of prices. With the PM/PM prices of the GUIDE care mannequin, we felt fairly that if we might keep away from one hospitalization in a yr, that primarily would pay for this program. In order that’s the important thing. We’re new individuals, three months into this system, so we do not have the information that we’re all searching for to make sure this actually is including worth to the healthcare system, versus simply including companies with out the worth. However that’s the angle we have come at this from. We perceive we’re distinctive within the sense that 65% of our sufferers have dementia. However we actually do wish to be leaders on this house, as a result of we have been delivering care to this inhabitants for occurring 20 years now.”
From a GUIDE-specific perspective, one of many early classes realized was that hiring was more difficult than Bluestone had anticipated. “Throughout the realm of care administration, we have now care coordinators, care managers and now care navigators. So I feel it was introducing a brand new lexicon on care navigation that was tripping us up just a little bit,” Hunkins stated, “so we have needed to mess around with how we promote this place to of us who wish to contribute to the betterment of dementia care.”
One other subject is affected person resistance. Bluestone was anticipating an 80% consent and enrollment price. In spite of everything, this can be a free profit for Medicare sufferers, These are Bluestone’s major care sufferers and 65% of them are eligible. “We thought this was going to be an precise slam-dunk in phrases o getting the consent and enrollment,” he remembers. “What we discovered is that this was far more difficult on the particular person affected person degree. We have run into a wide range of issues. Sufferers don’t belief something that is coming from the federal government.
We’re saying this can be a free profit to you out of your well being plan for Medicare, they usually assume that we’re attempting to tug one thing on them. We have needed to rework our language round that to say this can be a Bluestone providing, and it is lined out of your well being plan.”
Additionally, typically households and sufferers nonetheless do not wish to admit that they’ve dementia, he stated. “While you lead with, ‘Hey, that is the dementia program, folks will say, ‘We do not wish to discuss mother’s dementia,’ so there may be nonetheless nationwide stigma round dementia, and we’re encountering that, and we did not actually have that on our radar,” he stated. “The character of the dialog round dementia remains to be very delicate, a lot totally different than diabetes or a special power situation that is a bit more socially accepted, at the least inside society. So tweaking our language round how we current this program, how we describe it, and what advantages is provides all sort of tie into how we’re addressing a few of these consent challenges.”
Bluestone additionally needed to persuade its personal suppliers about this system. “That’s one other promoting level that we did not essentially anticipate,” Hunkins stated. “We knew we have been going to have to inform our suppliers about this system. However suppliers are similar to sufferers, within the sense that extra is not at all times higher, as a result of it complicates issues. I feel our suppliers thought if every little thing’s going properly, then why are we going so as to add this service? We have needed to present our suppliers what kind of issues are coming off of their plate that the care navigator can deal with.”
One other space is communication with caregivers. Bluestone has a device referred to as the Bluestone Bridge. It’s a primarily a digital care convention that goes on between the assisted dwelling nursing workers, house care or hospice, the caregiver and Bluestone suppliers. “It is an ongoing dialog just about and our suppliers are central to that,” he stated. “So when there is a change in situation, they’re responding to it. What we have been in a position to do is deflect among the site visitors and the time that our suppliers are spending on that device. Now we have not perfected that both, however we all know that that could be a good alternative for us to deliver worth again to our suppliers when it comes to promoting this program.”
Additionally, inside the assisted dwelling communities the place Bluestone delivers care, it has to promote this system to them as properly, in order that they perceive from their nursing workers perspective what worth that is bringing to that neighborhood. “A lot of what a affected person inside an assisted dwelling neighborhood is coping with does have an effect on the nursing workers inside the constructing,” Hunkins stated, “so we wish to, ensure that there’s worth add for the assisted dwelling neighborhood inside this program as properly.”
