Guiding an Improved Dementia Experience (GUIDE) Model

Mainers with dementia and their caregivers will soon have a place to turn for help. On July 1, Andwell Health Partners will launch its new GUIDE (Guiding an Improved Dementia Experience) program in partnership with the Centers for Medicare and Medicaid Innovation. This eight-year-long pilot program is designed to support both the individual with dementia and their caregiver.

“This is a really innovative program,” said Andwell’s Chief Clinical Officer, Carol Weir. “It will support not just the patient, but also the caregiver, who is typically the patient’s spouse or another family member.”

Caring for a loved one with dementia is incredibly demanding. Caregivers often face emotional stress, physical strain, and social isolation.

“Family members who aren’t living in the home don’t appreciate what that caregiver is going through day by day, hour by hour, minute by minute,” said Weir. “It’s so taxing. Something remembered yesterday isn’t remembered today; the sleepless nights—it can get very burdensome.”

GUIDE recognizes these challenges and offers vital support to caregivers, who are often unpaid family members or relatives assisting with activities of daily living. This support includes a variety of services designed to ease the caregiving burden.

Some caregivers and patients participating in GUIDE will qualify for an annual respite stipend, allowing them to receive in-home support while the caregiver takes time for themselves, whether for a medical appointment or simply to reconnect with friends. Additional caregiver support includes training on dementia care, support group services, one-on-one support calls, and education on self-care and well-being, as well as connection to community resources.

“We need to provide that support where we can for those who are caring for dementia patients,” Weir said. “Without the caregivers, these patients would eventually end up in facilities because they cannot care for themselves.”

In addition to caregiver support, GUIDE offers comprehensive care coordination for patients, ensuring proactive and personalized care. This includes annual home visits with environmental assessments, tailored care plans, and 24/7 access to after-hours support. Regular check-ins provide ongoing monitoring, while coordination with existing care teams helps to navigate the healthcare system. GUIDE also provides referrals for essential services, such as medication management, personal care, and community-based supports.