An individual is eligible if they meet all of the following criteria:

• Enrolled in Medicare Parts A and B and it’s their primary payer;
• Reside in the designated geographic area;
• Have an eligible dementia diagnosis;
• ARE NOT enrolled in a Medicare Advantage plan;
• ARE NOT enrolled in a Program for All-Inclusive Care for the Elderly (PACE);
• ARE NOT enrolled in the hospice benefit; and
• ARE NOT residing in a long-term skilled nursing home.

GUIDE has a variety of services included at no-cost to those patients enrolled. Before an individual can be enrolled in GUIDE, they must complete a comprehensive assessment with the GUIDE care team and be approved for participation by Medicare.

The comprehensive assessment uses a variety of self-administered and staff-administered standardized tools that assess the patient’s cognition, basic and instrumental activities of daily living, dementia stage, behavioral and psychosocial needs, health-related social needs, advance care planning, care team and caregiver (if applicable).

Once enrolled in GUIDE, the patient and caregiver have access to the following services:

• Home visit, from the GUIDE clinician, with environmental assessment, for moderate and high complexity patients.
• Establishing a care plan, with goals personalized to the patient, their dementia diagnosis, and helping them to improve their quality of life.
• 24/7 access through after-hours telephonic support and triaging.
• Ongoing monitoring and support through regular telephonic check-ins with GUIDE care team members.
• Care coordination with your existing care teams members outside of the Andwell Health Partners system and transitional care management as you navigate the healthcare system.
• Referral and coordination of services and supports that support the patient and caregiver in achieving goals identified in their care plan and/or needs identified in the comprehensive assessment. Referrals and supports may be healthcare or community-based services (e.g. personal care, environmental modifications, etc.).
• Medication management and reconciliation.
• Caregiver education and support tailored to the needs of the individual caregiver identified through the caregiver assessment.
• Respite allowance for caregivers of moderate and high complexity patients, allowing them time to focus on well-being.

Anyone can refer an eligible individual to the GUIDE program, including the patient, a family member or friend, someone from the patient care team (e.g. primary care or dementia diagnosing provider), or a community-based organization. If a provider is referring, we ask them to complete and return this referral form: patientservicecenter@andwell.org or fax to 207.777.7748.

If a patient, family member or friend is referring, call 207.795.9320. Please confirm eligibility under the above ‘Who is Eligible’ have the following information ready when you call:

• Patient’s name
• Date of birth
• Address
• Phone number
• Medicare number
• Email address,
• Primary care or dementia diagnosing provider’s name, practice name, and phone number, and
• If they have a caregiver, we will need their name, phone number, email address, and if they reside with the patient. The definition of a caregiver can be found in the next question.

A caregiver means a relative, or unpaid nonrelative, who assists the patient with activities of daily living and/or instrumental activities of daily living. Depending on the patient’s need, the assistance may be episodic, daily, or occasional. The caregiver does not need to live with the beneficiary and while no specific functions are required to be considered a caregiver, the caregiver should assist the beneficiary with activities of daily living, examples dressing, bathing, eating, preparing meals, mobility, toileting, and transferring.

Caregiver specific services include caregiver skills training, dementia diagnosis education, support group services, one-on-one support calls, education on a wide variety of topics related to caregiving including self-care/well-being, connection to community-based resources, and respite care (if eligible).