Programs - GUIDE

GUIDE Program

(Guiding an Improved Dementia Experience)

Good Shepherd Community Care is proud to participate in the GUIDE Model (Guiding an Improved Dementia Experience), a groundbreaking, Medicare-funded program designed to enhance care for individuals living with dementia and to support the families and caregivers who care for them. Enrollment for this comprehensive, person-centered program began on July 1, 2025, and will continue through June 2032.

The GUIDE Model was developed by the Centers for Medicare & Medicaid Services (CMS) as part of an eight-year national demonstration project. Its primary goals are to improve the quality of life for people living with dementia, reduce caregiver stress, and help delay or prevent long-term nursing home placement.

At the heart of Good Shepherd’s GUIDE Program is a dedicated, interdisciplinary team of nurse practitioners and care navigators who are specially trained to address the unique and evolving needs of people living with dementia and those who care for them. Our team brings together professionals from diverse disciplines to provide a holistic approach to assessment, care planning, and ongoing support.

By working closely with patients, families, medical providers, and community organizations, Good Shepherd's GUIDE team helps ensure that caregivers are empowered, informed, and never alone on their journey. 

Core Program Features:

  • Comprehensive Assessment & Individualized Care Planning: We develop personalized care plans through in-depth assessments that are tailored to help caregivers meet the evolving needs of individuals living with dementia.
  • Ongoing Care Coordination: We communicate and collaborate with medical providers, community-based organizations, and other key supports to ensure personalized, coordinated, well-rounded care.
  • Caregiver Education & Support: We offer resources, tools, and guidance to help reduce caregiver strain and increase caregiver confidence.
  • Respite Services: Select GUIDE participants may also be eligible for limited respite care services in the home, which can provide caregivers with essential time for rest and renewal.
  • 24/7 Support Line: Our 24/7 phone line is available to offer guidance and support focused on reducing caregiver strain and assistance with problem-solving.
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All services are fully covered by traditional Medicare with no out-of-pocket costs to eligible participants. 

Eligibility

To participate in the GUIDE Program, individuals must:

  • Have a diagnosis of mild, moderate, or severe dementia (excluding mild cognitive impairment). This may have already been determined by your medical team, or an assessment can be done by the nurse practitioner during the initial comprehensive assessment.  
  • Be enrolled in Medicare Parts A and B with Medicare as their primary payer.
  • Reside within Good Shepherd’s service area.
  • Not be currently enrolled in hospice, Medicare Advantage, SCO, or PACE plans

No medically appropriate person is ever denied care because of race, age, religion, diagnosis, sexual orientation, or inability to pay.

Why GUIDE Matters

The GUIDE Model reflects Good Shepherd’s unwavering commitment to providing care that honors the dignity, humanity, and unique needs of individuals living with dementia. Through this work, we strive to create a more compassionate, connected, and supportive experience for patients and caregivers—because no one should navigate dementia alone. 

How to Learn More

Families and healthcare providers interested in learning more about eligibility or referrals are encouraged to call Good Shepherd Community Care at 617-969-6130.

Testimonials