On July 1, 2024, the Facilities for Medicare & Medicaid Providers (CMS) Innovation Heart launched the Guiding an Improved Dementia Expertise (GUIDE) Mannequin, with 330 collaborating organizations presently constructing dementia care packages serving a whole lot of 1000’s of individuals with Medicare nationwide. On the latest fall assembly of the Nationwide Affiliation of ACOs (NAACOS), Bluestone ACO’s Nate Hunkins, M.P.H., shared some early classes realized in this system. 

The GUIDE Mannequin is slated to run for eight years and is among the first Innovation Heart care fashions to deal with longitudinal, condition-specific complete care, a key factor of the Innovation Heart’s 2022 Specialty Technique. Right now, practically 7 million People stay with Alzheimer’s illness or one other type of dementia, and, by 2060 the variety of People dwelling with dementia is anticipated to double to 14 million.

Eighty-nine organizations started their efficiency interval within the various fee mannequin on July 1, 2024, whereas 241 organizations had a one-year pre-implementation interval beginning July 1, 2024, and commenced their efficiency on July 1, 2025.

Below the mannequin, individuals are assigning folks with dementia and their caregivers to a care navigator who helps them entry GUIDE providers and helps and non-GUIDE providers and helps together with scientific providers and non-clinical providers resembling meals and transportation by community-based organizations. Mannequin individuals are additionally serving to caregivers entry respite providers, which allow them to take momentary breaks from their caregiving duties.

GUIDE individuals symbolize a variety of suppliers, together with massive educational medical facilities, small group practices, community-based organizations, well being techniques, hospice businesses, and different practices.

Talking on a NAACOS panel, Hunkins first gave some background about Bluestone and why GUIDE made a lot sense for them to take part in. “At Bluestone, we consider sufferers with complicated power circumstances deserve superior main care,” he stated. “We offer main care and deal with assisted dwelling communities. Bluestone actually is a distinct segment supplier within the sense that we’re not in expert nursing amenities. We perform a little little bit of impartial dwelling, however we’re primarily an assisted dwelling main care group throughout three markets — Minnesota, Florida and Wisconsin.”

Bluestone ACO saved Medicare $33.6 million in 2024 as a part of the Medicare Shared Financial savings Program (MSSP) by its care for five,772 Medicare beneficiaries who reside at assisted dwelling, reminiscence care, and group residence communities. Bluestone ACO will increase its mannequin in 2026 in partnership with Herself Well being, an organization offering complete main care to ladies as they age and mature.

The common age of Bluestone’s inhabitants is 82, with a median of seven power circumstances. Roughly 65% of its sufferers are eligible for GUIDE.

“Whether or not or to not enter GUIDE felt like a fairly simple resolution, conceptually, as a result of this can be a inhabitants that we serve at scale basically,” he stated. “We have now care coordination. We name it complicated care administration. We have got behavioral well being specialists who’re integrating inside our main care. So once we checked out GUIDE, the true query was that we have a lot ancillary assist inside our superior main care mannequin, how do we actually slot in GUIDE in order that we’re not overlapping providers and actually contributing to higher prices inside the healthcare system? We’d like to have the ability to ship this effectively. We have now not figured that out completely, however that was the premise that we understood from the start — that this has to combine with our mannequin, not simply be additive by way of price and further providers with out true worth to the sufferers.”

When Bluestone execs checked out which GUIDE providers it’s not providing inside its superior main care mannequin, they realized it was having a devoted care navigation for all the eligible residents and caregivers.

“Beforehand, we weren’t doing a full wants evaluation, together with the SDOH element for our sufferers with dementia, so we did see that as a possibility to leverage that data to supply extra complete look after our sufferers,” Hunkins stated. “We noticed that the dementia care navigator might truly take a few of this superior care planning from our main care suppliers and assist tee up a few of that dialog and actually work with the caregiver, together with the affected person in having that dialog.”

Hunkins stated one other piece of that is being extra delicate to alter in circumstances. As an ACO, they need to make sure that they’re stopping hospitalizations and the transition to long-term care. “We wanted to make it possible for our dementia care navigators had been including worth round transitions of care. How are we making certain that we’re looping in your complete workforce to make the fitting resolution on the fitting stage of look after the sufferers?”

Even previous to the GUIDE mannequin, Hunkins stated, they estimated about 20% to 25% of their ED visits had been avoidable. “What we have performed is figure on how we intervene upstream. Additionally, if our sufferers enter the ED, how can we intervene on the ED so that does not result in an admission. Many individuals within the dementia inhabitants cannot advocate for themselves. They can not truly articulate what their needs are. We see that as our accountability as main care and a GUIDE participant —  to make it possible for we’re advocating alongside the caregiver, if they’ve one, to make sure they get the fitting stage of care inside the hospital setting, as a result of the default for somebody who cannot articulate their wants is to get them admitted,” he defined. “We’re attempting to make it possible for we have now documentation of what these affected person needs are, after which have care navigators, in collaboration with our complicated care managers, intervening inside that ED.”

Primarily, Bluestone noticed GUIDE as a lever for value-based care and general ACO enchancment. “For us, there actually wasn’t a query of whether or not we had been going to do it, but it surely was a matter of how we will guarantee this is not going to be additive and result in higher prices inside our ACO,” Hunkins stated. “We do assume that avoiding hospitalizations and doing extra proactive, superior care planning are the levers to have the ability to create the offset of prices. With the PM/PM prices of the GUIDE care mannequin, we felt fairly that if we might keep away from one hospitalization in a yr, that basically would pay for this program. In order that’s the important thing. We’re new individuals, three months into this system, so we do not have the information that we’re all on the lookout for to make sure this actually is including worth to the healthcare system, versus simply including providers with out the worth. However that’s the angle we have come at this from. We perceive we’re distinctive within the sense that 65% of our sufferers have dementia. However we actually do need to be leaders on this house, as a result of we have been delivering care to this inhabitants for happening 20 years now.”

From a GUIDE-specific perspective, one of many early classes realized was that hiring was more difficult than Bluestone had anticipated. “Inside the realm of care administration, we have now care coordinators, care managers and now care navigators. So I believe it was introducing a brand new lexicon on care navigation that was tripping us up a bit bit,” Hunkins stated, “so we have needed to mess around with how we promote this place to of us who need to contribute to the betterment of dementia care.”

One other concern is affected person resistance. Bluestone was anticipating an 80% consent and enrollment charge. In spite of everything, this can be a free profit for Medicare sufferers, These are Bluestone’s main care sufferers and 65% of them are eligible. “We thought this was going to be an precise slam-dunk in phrases o getting the consent and enrollment,” he remembers. “What we discovered is that this was rather more difficult on the particular person affected person stage. We have run into quite a lot of issues. Sufferers don’t belief something that is coming from the federal government.
We’re saying this can be a free profit to you out of your well being plan for Medicare, and so they assume that we’re attempting to tug one thing on them. We have needed to rework our language round that to say this can be a Bluestone providing, and it is coated out of your well being plan.”

Additionally, generally households and sufferers nonetheless do not need to admit that they’ve dementia, he stated. “Whenever you lead with, ‘Hey, that is the dementia program, folks will say, ‘We do not need to speak about mother’s dementia,’ so there may be nonetheless nationwide stigma round dementia, and we’re encountering that, and we did not actually have that on our radar,” he stated. “The character of the dialog round dementia remains to be very delicate, a lot completely different than diabetes or a unique power situation that is a bit more socially accepted, no less than inside society. So tweaking our language round how we current this program, how we describe it, and what advantages is gives all form of tie into how we’re addressing a few of these consent challenges.”

Bluestone additionally needed to persuade its personal suppliers about this system. “That’s one other promoting level that we did not essentially anticipate,” Hunkins stated. “We knew we had been going to have to inform our suppliers about this system. However suppliers are similar to sufferers, within the sense that extra is not all the time higher, as a result of it complicates issues. I believe our suppliers thought if all the things’s going effectively, then why are we going so as to add this service? We have needed to present our suppliers what kind of issues are coming off of their plate that the care navigator can deal with.”

One other space is communication with caregivers. Bluestone has a software referred to as the Bluestone Bridge. It’s a basically a digital care convention that goes on between the assisted dwelling nursing employees, residence care or hospice, the caregiver and Bluestone suppliers. “It is an ongoing dialog just about and our suppliers are central to that,” he stated. “So when there is a change in situation, they’re responding to it. What we have been in a position to do is deflect a few of the site visitors and the time that our suppliers are spending on that software. Now we’ve not perfected that both, however we all know that that may be a good alternative for us to carry worth again to our suppliers by way of promoting this program.”

Additionally, inside the assisted dwelling communities the place Bluestone delivers care, it has to promote this system to them as effectively, in order that they perceive from their nursing employees perspective what worth that is bringing to that neighborhood. “A lot of what a affected person inside an assisted dwelling neighborhood is coping with does have an effect on the nursing employees inside the constructing,” Hunkins stated, “so we need to, make it possible for there’s worth add for the assisted dwelling neighborhood inside this program as effectively.”