GUIDE Dementia Support Program
AMG’s GUIDE program provides comprehensive dementia care coordination plus caregiver education, support, and (for qualifying families) respite services—so you don’t have to navigate this alone.
GUIDE is a CMS Innovation Center model that expands Medicare coverage for dementia care coordination and caregiver support.
What is GUIDE?
GUIDE (Guiding an Improved Dementia Experience) is a national Medicare model designed to improve quality of life for people living with dementia and reduce caregiver strain through team- based care coordination, ongoing caregiver support, and access to respite services for qualifying caregivers.
At AMG, our goal is simple: make dementia care more organized, proactive, and supportive— for both the patient and the caregiver.
Who is this program for?
GUIDE is for community-dwelling Medicare fee-for-service beneficiaries living with dementia (including people who are dually eligible for Medicare and Medicaid).
You may be a good fit if you or your loved one:
What families receive through AMG’s GUIDE program
1) A dementia care navigator + interdisciplinary team
You’ll have a consistent point of contact to help coordinate care, answer questions, and connect you to resources—backed by an interdisciplinary dementia care team.
2) A dementia-focused care plan
We create and update a personalized care plan that addresses dementia symptoms, safety needs,
caregiver goals, and co-occurring conditions—then help coordinate care across your medical team and community supports.
3) Caregiver education + ongoing support
Caregivers receive ongoing support, monitoring, and guidance—including access to help when questions come up.
4) 24/7 support line
GUIDE includes 24/7 access to a support line for caregivers/patients for urgent guidance and care navigation.
5) Respite services for qualifying caregivers
Some families qualify for respite services up to an annual cap, providing temporary relief via options like in-home respite, adult day services, or short-term facility-based respite (availability varies locally).
Why this matters
Dementia is not just memory loss—it affects function, safety, medication management, behavior, caregiver wellbeing, and long-term planning. GUIDE is built to reduce avoidable crises and improve support over time.
How to get started
GUIDE (Guiding an Improved Dementia Experience) is a national Medicare model designed to improve quality of life for people living with dementia and reduce caregiver strain through team- based care coordination, ongoing caregiver support, and access to respite services for qualifying caregivers.
Families & caregivers
- Click Request a GUIDE Consult
- Our team will contact you to confirm eligibility and next steps
- If aligned, we’ll schedule your intake and begin care planning
Providers, facilities, and community partners
- Click Refer a Patient to GUIDE
- Or call our office to coordinate directly with our navigator team
What to include in a referral (helpful):
- Dementia diagnosis (if known) and current living setting
- Caregiver contact info (if available)
- Top concerns (falls, meds, behaviors, caregiver burnout, safety)
Frequently Asked Questions
Does GUIDE cost anything?
GUIDE is a CMS model that expands coverage for dementia care coordination and caregiver support for eligible Medicare beneficiaries. (Any cost-sharing, if applicable, depends on the beneficiary’s coverage details.)
Is respite available for everyone in GUIDE?
Respite is available for qualifying caregivers (criteria include patient/caregiver tiering and complexity).
Do you replace the patient’s primary care provider?
No—GUIDE is designed to coordinate dementia-focused care and caregiver supports, and to partner with the patient’s existing clinicians and community resources.
What kinds of dementia are included?
GUIDE is intended for Medicare beneficiaries living with dementia, including Alzheimer’s disease and other dementias, across disease stages.
What if we don’t have a caregiver?
GUIDE is built around supporting patients and unpaid caregivers, and caregiver involvement impacts what services (like respite) may be available. We can still talk through your situation and resources.
If dementia is affecting daily life, safety, or caregiver stress, AMG’s GUIDE team can help.
