Your Kern County Partner in Dementia Care

Caring for someone with dementia can be one of the most demanding roles a person can take on. More than 7 million Americans are currently living with dementia and the number of persons diagnosed each year continues to rise.

Help Throughout the Dementia Journey

The GUIDE Program (Guiding an Improved Dementia Experience) was created by the Centers for Medicare and Medicaid Services (CMS) to stand beside participants and their caregivers. It is a nationwide program that began on July 1, 2024, and will run for eight years through June 2032.  GUIDE helps participants and caregivers navigate a care system that can otherwise feel fragmented. 

Kern County Aging & Adult Services (KCAASD), the local Area Agency on Aging, serves as a partner to caregivers and participants in delivering the GUIDE Program, providing compassionate, respectful, and practical support throughout the dementia experience. 

GUIDE is completely voluntary – a person who is participating in GUIDE can stop at any time, and their regular Medicare benefits continue as usual. They can still see any doctor or hospital that accepts Medicare.

What is the GUIDE Program?

GUIDE is a Medicare program that provides enhanced services for dementia care and aims to improve care coordination and reduce caregiver strain by helping caregivers access services and supports. Through GUIDE, a person with dementia can gain access to comprehensive services at no cost beyond their existing Medicare coverage.

Program Goals

• Improve the quality of life for people living with dementia
• Enhance support for caregivers of people living with dementia
• Help people living with dementia stay in their homes and communities longer

Care delivery areas that the GUIDE program provides

• Comprehensive assessment (patient + caregiver) - Once the person who may have dementia or has a confirmed diagnosis of dementia (the participant) has elected to enroll with the GUIDE program, Kern County Aging and Adult Services will conduct a comprehensive assessment, which includes an in-home safety assessment.
• Person-centered care plan - After the assessment is completed, the GUIDE program medical team will create a wellness plan specific to the participant’s needs
• Ongoing monitoring and support – The participant/caregiver will be in touch with our Kern County Aging and Adult Services Care Navigator on a monthly basis (more if needed).
• 24/7 access to the care team / support line – The participant/caregiver will have access to our 24/7 support line is a support line for urgent questions and concerns, and it is part of the care team’s support for clinical and care needs.
• Care coordination (including primary care + specialists) - The GUIDE program Navigator will assist in making appointments or finding other care programs if needed.
• Transitional care management - If the time comes when the participant is no longer able to stay in their own home, the GUIDE program will assist in that transition.
• Medication management & reconciliation – The GUIDE program medical group will review the participant’s medication list and make suggestions if they think something could be changed for the better.
• Referral to and coordination of community-based services – The GUIDE program Navigator will assist in finding community-based services that the participant/caregiver would need or like to try.
• Caregiver education, training, and support (including respite services). GUIDE participants with moderate to severe dementia who have an unpaid caregiver are eligible to receive a yearly benefit that pays up to $2,536 for temporary relief services from an authorized respite provider.  * The respite benefit is not paid to the Referred person or their caregivers.  Instead, the Respite benefit is provided by KCAASD GUIDE Program-officially authorized contracted providers who provide respite that allows unpaid caregivers to take time off from their unpaid caregiving duties.

Who Can Participate in the GUIDE Program?

1. Suspected/Confirmed Dementia Diagnosis
2. Living in the Community (home or room and board)
3. Has an unpaid caregiver (Family/Friend)
4. Enrolled in Traditional Medicare
5. Not Currently Aligned to (Enrolled with) Another GUIDE PROVIDER

What Factors Disqualify Participation?

1. Cannot have Medicare Advantage (Part C)/Medicare Special Needs Plans
2. Cannot be in a PACE program
3. Cannot be in Hospice
4. Cannot be Long-Term Nursing Home Resident
5. Cannot be in Memory Care Residence

How the GUIDE Program Works

Step 1:   Referral - Anyone can refer – family, friends, support workers, physicians, community organizations, etc.

Step 2:   Comprehensive Assessment – The participant and caregiver are scheduled for an assessment covering cognition, functional status, home safety, and caregiver burden.

Step 3:   Enrollment in the GUIDE Program – GUIDE team sends information to CMS for eligibility verification and official enrollment into the GUIDE program.

Step 4:   Personalized Wellness Plan – GUIDE team develops a person-centered and annually reviewed wellness plan tailored to the family’s needs.

Step 5:   Ongoing Support – Care management, access to the care team / support line, caregiver education/support, respite services for eligible participants, community resource connections.

Who Can Refer?

Anyone can refer a potential GUIDE participant: 

1. Family members or caregivers
2. Medical providers
3. Social Workers
4. Community organizations
5. Others

How to refer a person to the GUIDE program

Please fill out the GUIDE form in order to refer a client or family member.

Be prepared to share

1. Participant’s name, phone, address, and zip code
2. Medicare card number
3. Caregivers name, phone, and relationship
4. Reason for referral
5. Your name, agency (if applicable), and preferred contact method

Tips for success

1. If you are unsure whether someone has Traditional Medicare, send the referral anyway. The GUIDE Program team will help determine eligibility.
2. Send referrals promptly, delays can postpone access to respite

Kern County GUIDE Program FAQs

Additional information about the Medicare GUIDE Model is available here.