From Policy to Practice: Enabling Real-World Success

GUIDE challenges providers to redesign how dementia care is delivered — requiring not only clinical coordination, but also social support, respite services, and real-time documentation. The model is bold, necessary, and complex to execute.

At Carecierge, we’ve been working closely with providers across the country as they translate this national vision into day-to-day reality. One thing is clear: success depends not just on policy — but on infrastructure, clarity, and execution.

While CMS has published a growing list of participating organizations, many groups are delivering GUIDE services across multiple sites, partnerships, and care settings. Each implementation is unique, but the challenges they face are consistent:

- Defining the Care Navigator role

- Tracking patient and caregiver services in real time

- Coordinating clinical and non-clinical care

- Managing CMS documentation and compliance requirements

Carecierge was built to solve exactly these challenges. Our platform and implementation team work directly with GUIDE participants to support program launch, streamline daily workflows, and ensure all required elements — from eligibility to respite tracking — are managed cleanly, without burdening staff.

What We’re Learning on the Ground

Drawing from active implementations across eight states, here are some of the clearest lessons emerging from the field:

1. Pre-Implementation Planning Drives Early Momentum

Teams that used the pre-implementation period to establish infrastructure — not just check compliance boxes — launched more smoothly and reached scale faster. Early preparation around navigator workflows, patient tracking, and HRSN referrals is paying off in smoother handoffs and fewer delays.

2. Care Navigator Role Must Be Operationalized, Not Assumed

While GUIDE emphasizes the importance of a Care Navigator, many teams struggled to define this role at launch. Carecierge helps clients build structured navigator workflows with clear responsibilities, documentation tools, and integration into clinical and behavioral health processes. The result: stronger coordination, better visibility, and more confident staff.

3. Respite and Social Needs Support Drive Engagement

GUIDE participants who embrace these non-clinical components as core to care — not secondary services — are seeing higher caregiver satisfaction and better continuity. Embedding respite tracking and HRSN screening into the standard patient workflow avoids fragmentation and improves program adherence.

4. Automation Reduces Risk and Lifts Teams

Documenting all required touchpoints — care plans, referrals, navigator interactions, caregiver education — is a heavy lift without the right systems in place. Our platform reduces that burden through structured automation, which allows teams to remain CMS-compliant without slowing down care delivery.

Participant Spotlight: Vesper Medical Care

One of our early GUIDE partners, Vesper Medical Care, enrolled 60+ dementia patients within the first two weeks of going live. Using Carecierge’s tools to manage onboarding, navigator tracking, and documentation, Vesper reported:

- Faster-than-expected enrollment

- Streamlined documentation workflows

- Stronger alignment between care and support teams

Their experience shows what’s possible when the right team and platform come together from day one.

Our Commitment

At Carecierge, we believe the GUIDE Model represents a turning point in American dementia care — and we’re committed to helping organizations deliver on its promise.

Whether you're just getting started or need help navigating daily workflows, our mission is to make GUIDE easier to implement, more reliable to manage, and better for the patients and caregivers it was built to serve.

If your team is participating in GUIDE and looking for a partner to help you succeed, we’d love to talk.