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Medicare is quietly rolling out something dementia families have begged for: ongoing support that doesn’t end when the appointment does. We sit down with Nancy Gillette, Chief Growth Officer at PocketRN, to explain the CMS GUIDE Model (Guiding an Improved Dementia Experience) in plain English, including what it pays for, how it’s delivered virtually by experienced RNs, and why it’s a true shift in dementia care, caregiver support, and aging in place. 

We dig into eligibility and exclusions with the details that trip people up in real life: traditional Medicare Part A and B plus a dementia diagnosis is the baseline, all dementias qualify, and many people can still participate while receiving Medicaid services, veteran benefits, palliative care, or living in assisted living or memory care. We also cover the common deal-breakers like Medicare Advantage, hospice, PACE, and long-term nursing home residency, plus what paperwork typically works to prove the diagnosis. 

Then we get into what GUIDE actually delivers across nine care domains, from comprehensive assessment and care planning to caregiver training, medication reconciliation, referral coordination, and ongoing monitoring designed to catch changes before they turn into an ER visit. Finally, we clarify the respite benefit everyone asks about: 72 hours per year for moderate to severe complexity, used in four-hour increments, on a July 1 to June 30 “use it or lose it” cycle, and how home care partners can get paid for required in-person safety visits and respite coverage. 

If you support dementia clients or family caregivers, listen through to the Q&A and the real case stories about doors opening with discharge planners and senior living communities. Subscribe, share this with a colleague, and leave a review so more families can actually find these Medicare dementia care resources.

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