On July 1, 2024, the Facilities for Medicare & Medicaid Companies (CMS) Innovation Heart launched the Guiding an Improved Dementia Expertise (GUIDE) Mannequin, with 330 taking part organizations at present constructing dementia care packages serving tons of 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 give attention to longitudinal, condition-specific complete care, a key aspect of the Innovation Heart’s 2022 Specialty Technique. In the present day, practically 7 million People stay with Alzheimer’s illness or one other type of dementia, and, by 2060 the variety of People residing 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, contributors are assigning folks with dementia and their caregivers to a care navigator who helps them entry GUIDE companies and helps and non-GUIDE companies and helps together with scientific companies and non-clinical companies resembling meals and transportation by means of community-based organizations. Mannequin contributors are additionally serving to caregivers entry respite companies, which allow them to take short-term breaks from their caregiving tasks.
GUIDE contributors symbolize a variety of suppliers, together with giant tutorial medical facilities, small group practices, community-based organizations, well being techniques, hospice companies, 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 imagine sufferers with advanced continual situations deserve superior main care,” he mentioned. “We offer main care and give attention to assisted residing communities. Bluestone actually is a distinct segment supplier within the sense that we’re not in expert nursing amenities. We do some little bit of unbiased residing, however we’re primarily an assisted residing 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 means of its care for five,772 Medicare beneficiaries who reside at assisted residing, reminiscence care, and group residence communities. Bluestone ACO will broaden its mannequin in 2026 in partnership with Herself Well being, an organization offering complete main care to ladies as they age and mature.
The typical age of Bluestone’s inhabitants is 82, with a median of seven continual situations. Roughly 65% of its sufferers are eligible for GUIDE.
“Whether or not or to not enter GUIDE felt like a reasonably simple determination, conceptually, as a result of this can be a inhabitants that we serve at scale primarily,” he mentioned. “Now we have care coordination. We name it advanced care administration. We have got behavioral well being specialists who’re integrating inside our main care. So after we checked out GUIDE, the actual query was that we have got a lot ancillary assist inside our superior main care mannequin, how do we actually slot in GUIDE in order that we’re not overlapping companies and actually contributing to larger prices throughout the healthcare system? We want to have the ability to ship this effectively. Now we have 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 when it comes to price and additional companies with out true worth to the sufferers.”
When Bluestone execs checked out which GUIDE companies 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 part for our sufferers with dementia, so we did see that as a possibility to leverage that info to offer extra complete take care of our sufferers,” Hunkins mentioned. “We noticed that the dementia care navigator might really 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 mentioned one other piece of that is being extra delicate to alter in situations. As an ACO, they need to make sure that they’re stopping hospitalizations and the transition to long-term care. “We would have liked to ensure that our dementia care navigators had been including worth round transitions of care. How are we guaranteeing that we’re looping in your entire crew to make the appropriate determination on the appropriate stage of take care of the sufferers?”
Even previous to the GUIDE mannequin, Hunkins mentioned, they estimated about 20% to 25% of their ED visits had been avoidable. “What we have accomplished 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 really articulate what their needs are. We see that as our accountability as main care and a GUIDE participant — to ensure that we’re advocating alongside the caregiver, if they’ve one, to make sure they get the appropriate stage of care throughout 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 making an attempt to ensure that we have now documentation of what these affected person needs are, after which have care navigators, in collaboration with our advanced care managers, intervening inside that ED.”
Basically, Bluestone noticed GUIDE as a lever for value-based care and total 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 are able to guarantee this is not going to be additive and result in larger prices inside our ACO,” Hunkins mentioned. “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 primarily would pay for this program. In order that’s the important thing. We’re new contributors, three months into this system, so we do not have the info that we’re all on the lookout for to make sure this actually is including worth to the healthcare system, versus simply including companies 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 tougher 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 mentioned, “so we have needed to mess around with how we promote this place to people who need to contribute to the betterment of dementia care.”
One other challenge is affected person resistance. Bluestone was anticipating an 80% consent and enrollment fee. In any case, 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 far more difficult on the particular person affected person stage. We have run into a wide range 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 making an attempt to drag 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, typically households and sufferers nonetheless do not need to admit that they’ve dementia, he mentioned. “Whenever you lead with, ‘Hey, that is the dementia program, folks will say, ‘We do not need to discuss mother’s dementia,’ so there’s nonetheless nationwide stigma round dementia, and we’re encountering that, and we did not actually have that on our radar,” he mentioned. “The character of the dialog round dementia remains to be very delicate, a lot totally different than diabetes or a unique continual 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 affords all type 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 mentioned. “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 at all times higher, as a result of it complicates issues. I believe our suppliers thought if all the pieces’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 known as the Bluestone Bridge. It’s a primarily a digital care convention that goes on between the assisted residing nursing employees, residence care or hospice, the caregiver and Bluestone suppliers. “It is an ongoing dialog nearly and our suppliers are central to that,” he mentioned. “So when there is a change in situation, they’re responding to it. What we have been in a position to do is deflect among the 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 could be a good alternative for us to convey worth again to our suppliers when it comes to promoting this program.”
Additionally, throughout the assisted residing 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 group. “A lot of what a affected person inside an assisted residing group is coping with does have an effect on the nursing employees throughout the constructing,” Hunkins mentioned, “so we need to, ensure that there’s worth add for the assisted residing group inside this program as effectively.”
