By Rhonda Quintana, Ceresti Chief Revenue Officer

CMS is making a bold move with its GUIDE (Guiding an Improved Dementia Experience) Model, signaling that dementia care is now a national priority. GUIDE aims to keep traditional Medicare beneficiaries with dementia living independently as long as possible by addressing gaps in family caregiver education, training and support as well as the lack of provider reimbursement for needed care coordination. 

The GUIDE program reflects a clear recognition from CMS that dementia is a major driver of avoidable costs and suboptimal outcomes, particularly in the value-based care ecosystem.

ACOs and at-risk providers that embrace GUIDE today will emerge as leaders tomorrow, as CMS accelerates its focus on dementia care. Beyond improving patient outcomes, the right GUIDE partner ensures that ACOs can effectively manage attribution, control medical expenses, and reduce preventable hospitalizations—protecting both their financial performance and their ability to deliver high-quality care. 

For ACOs, GUIDE presents an opportunity to align with CMS priorities—but it also introduces new challenges.

Why GUIDE is a High-Stakes Play for ACOs

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ACOs should be thinking strategically about how they leverage the benefits of GUIDE on behalf of their dementia patients. While the program promises shared savings through fewer hospitalizations and ED visits, there are risks that a well-prepared partner can help you avoid.

1. Attribution & Cost Control Risks – Unaffiliated GUIDE providers can potentially disrupt patient attribution, misalign financial incentives, and fragment care. On the other hand, GUIDE providers that are aligned with ACO priorities won't increase medical expenses, they will lower them. Once a dementia patient is institutionalized in a long-term care facility, they often fall off PCP attribution and may transition care to another provider, into a PACE program, or other special needs health plan. That means your ACO loses that patient—and the opportunity to impact their outcomes and cost of care. The right partner addresses both the care challenge and alleviates the financial risk to the ACO through a strategy for keeping dementia patients stable at home.
2. Lack of Caregiver Preparedness = More Crises – Aging at home improves health outcomes, as long as family caregivers are well-prepared, educated and supported.  ACOs relying on underprepared family caregivers will risk accelerating long-term care placement, which leads to higher readmission rates, worsened health outcomes, and increased costs. Research published in Neurology also found that nonelective hospitalizations more than double the rate of cognitive decline in older adults, increasing the likelihood of long-term care placement. Preventing avoidable hospitalizations by preparing family caregivers isn’t just about reducing costs—it’s about slowing disease progression and helping patients maintain independence by aging at home for as long as possible.
3. Not All GUIDE Providers Are the Same – Many organizations entering the GUIDE space are new to the program’s requirements and lack proven results in reducing costs and improving outcomes. Conversely, those with proven tech-enabled programs make it possible to scale caregiver enrollment, personalize education, and track engagement in real time. Others may have expertise in hospice, palliative care, or institutionalized patients, but lack experience in activating dementia patients and caregivers earlier in the disease trajectory—where proactive intervention is critical. It is also critical to find a partner with the expertise  to interpret and analyze dementia-specific data and drive meaningful population health insights that align with ACO performance goals.

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For ACOs, choosing the right GUIDE provider isn’t just about meeting program requirements—it’s about ensuring caregiver engagement is scalable, education is personalized, and dementia care is proactive, not reactive. With these capabilities, ACOs can realize GUIDE’s full cost-saving and quality-improving potential.

Are Your Family Caregivers Prepared?

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Family caregivers are the first line of defense in preventing unnecessary hospitalizations, but most are untrained, unsupported, and unprepared to recognize and act on early warning signs of a change in condition.

• Most family caregivers are managing complex medical tasks—without training. Studies show that over 60% of dementia caregivers perform medical or nursing tasks, such as managing medications and wounds, and using medical equipment—yet the majority report receiving little to no formal training. Without preparation, these caregivers are more likely to struggle with navigating their loved one’s care, leading to medication errors, preventable hospitalizations, and poor health outcomes.
• GUIDE is designed to provide comprehensive, coordinated care that includes caregiver education, training, and respite services—a recognition that family caregivers play a crucial role in keeping dementia patients stable and out of the hospital.

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ACOs that prepare family caregivers to intervene early prevent avoidable hospitalizations, improve patient outcomes, and drive down costs.

How ACOs Can Lead with GUIDE (and Avoid Costly Mistakes)

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GUIDE is an opportunity for ACOs to get dementia care right—but only with the right partner. The difference between success and failure comes down to how well caregivers are prepared.

The right GUIDE provider will:
✅ Accelerate Implementation – Use proven care models and training frameworks to rapidly prepare caregivers to recognize and respond to changes in condition.
✅ Handle Enrollment – Since caregivers aren’t the patients, ACOs need a GUIDE provider that can efficiently identify, enroll, and activate caregivers at scale.
✅ Mitigate Risk – Ensure alignment with ACO attribution and control medical expenses by proactively managing dementia-related crises.
✅ Guarantee Outcomes – The best GUIDE providers align financial incentives with ACO savings goals, ensuring that reduced medical expense outweighs program costs.

This can make the difference between a GUIDE provider that helps ACOs win and one that increases costs.

Doing Nothing is Not Free

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In my previous article, “Doing Nothing Is Not Free: ACOs and GUIDE,” I highlighted why inaction is the most expensive decision. The GUIDE model reinforces this reality: ACOs that fail to prepare caregivers will see higher medical costs, more crises, and worse patient outcomes.

Aligning with a proven GUIDE provider is not just a smart decision—it’s a financial necessity. ACOs that don’t act now risk being left behind as CMS accelerates its focus on dementia care.  ACOs that invest in preparing caregivers will gain a competitive edge in value-based care, driving better outcomes and lower costs.

The question isn’t whether ACOs can afford to invest in caregiver-inclusive dementia care.

The question is: Can they afford not to?

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