Navigating Dementia Care through GUIDE

Caring for someone with dementia can feel overwhelming as needs change and decisions feel more urgent. Many families find themselves searching for reassurance and support as they navigate the complex healthcare system during these stressful, uncertain moments.  

Bluestone Dementia Care services, delivered through Medicare’s GUIDE Model, bring clarity, consistency and real partnership to families living with dementia, so they don’t have to navigate the journey alone.  

 Below, you’ll find answers to common questions. Explore the sections that matter most to you: 

• About GUIDE & Bluestone Dementia Care Navigation
• Eligibility & cost 
• Caregiver support & involvement 
• Coordinating care & common questions
• How to enroll
• Explore Elaine’s story — an example of a family’s dementia journey supported by Bluestone

Fill out an enrollment interest form and a Bluestone team member will be in touch. 

ABOUT GUIDE & DEMENTIA CARE NAVIGATION 

What is the GUIDE Model? 

Medicare created the GUIDE Model (Guiding an Improved Dementia Experience) to support people living with dementia and the caregivers who help care for them. GUIDE provides families with a dedicated Dementia Care Navigator — someone who understands dementia, knows how to navigate the healthcare system and helps them through decisions as needs change over time. 

Think of a Dementia Care Navigator as having “someone by your side.” Instead of trying to figure everything out on your own, they are a consistent point of contact who knows and understands your situation and helps you plan for what comes next. Review this infographic to 

How do Bluestone Dementia Care Navigation services support people living with dementia and their caregivers? 

What sets us apart is our team-based approach built on trust and partnership — our teams live and work in the same geographic areas as our patients and families, which allows us to build deep relationships. Dementia Care Navigators are nurses or social workers who: 

• Provide 24/7 support to patients and caregivers, both in person and virtually 

• Visit communities regularly to listen, observe and collaborate directly with community staff 

• Build strong, trusted relationships through consistent, ongoing partnership

“Caregivers don’t just need help in emergencies — they need ongoing support, education, and reassurance from someone who truly knows their situation. Throughout the dementia journey, our team provides steady guidance, so families feel less alone and more prepared. When questions arise or something doesn’t feel right, we’re there to help them think things through with confidence.”
— Martha Etzell, Bluestone vice president of Value-Based Care Management

 

Dementia Care Navigators help with: 

• Understanding dementia and what to expect as it progresses 

• Connecting caregivers to education, resources and support groups 

• Coordinating care across providers, settings and care transitions 

• Collaborating with care teams and community staff to ensure everyone is aligned 

• Helping identify safety and environmental needs 

• Supporting equipment needs, such as adaptive or sensory tools 

• Supporting patients and families during emergency room visits or hospital stays 

 

What services are not included with Dementia Care Navigation? 

Dementia Care Navigators do not provide hands-on daily care, such as bathing, dressing, or physical therapy. These services are delivered by community staff, home health, or therapy providers. Care Navigators can identify needs and work with their primary care provider to coordinate these services. 

 

Do Dementia Care Navigators visit my loved one in person? 

Yes. Dementia Care Navigators meet with patients in person during the assessment process and schedule regular in-person visits as needed. They also are available for regular check-ins via phone or email with caregivers.  

“It’s deeply reassuring for families to know someone can be there in person. Our Care Navigators live in the community, which allows them to see what’s really happening, collaborate closely with staff, and support families in ways that simply aren’t possible remotely. Especially when a loved one is nonverbal or difficult to assess, that in-person presence brings peace of mind and confidence in their care.”

— Martha Etzell, Bluestone Vice President, Value Based Care Management

CAREGIVER SUPPORT & INVOLVEMENT 

What is expected of caregivers? 

A common concern we hear is, “I’m already overwhelmed. Will this be one more thing I have to manage?” GUIDE is designed to reduce stress, not create it. We adapt to what works best for each person and family  

At a minimum, caregivers are asked to: 

• Share information during conversations 

• Complete the required Medicare caregiver questionnaire 

• Stay connected in a way that feels manageable to them — whether that’s communicating over phone calls, email or the Bluestone Bridge — our secure communication tool. 

 Can caregivers who live out of state still be involved? What if multiple family members are helping? 

Yes. Many caregivers live out of state or share responsibilities with siblings or other family members. Dementia Care Navigators work with the caregiver structure that exists. With permission from the patient or medical power of attorney, Dementia Care Navigators can include multiple caregivers in conversations, provide updates and help coordinate communication, so everyone feels informed and supported, regardless of location. 

 Is respite care available? 

Eligible caregivers may receive up to $2,500 per year in respite care, covered by Medicare. Respite services are intended to give caregivers time to rest, attend appointments or recharge. Medicare determines eligibility for the respite benefit based on the caregiver questionnaire and the severity of dementia progression. There is no cost for families for GUIDE services. 

COORDINATING CARE & OTHER COMMON QUESTIONS 

What if my family member already has a primary care provider who isn’t with Bluestone? 

If your family member receives primary care from another provider, your Dementia Care Navigator will collaborate with them to share observations, coordinate recommendations and support continuity of care. GUIDE is designed to complement existing medical care, not replace it.  

 What if my family member is hesitant or resistant to extra support? 

This is common. Many people living with dementia are wary of new providers or don’t feel they need help. Dementia Care Navigators are trained to build trust gradually and meet people where they are. This begins by focusing on practical needs and caregiver support rather than labeling the program as “dementia care.” Enrollment and participation are never forced, and care is always approached with respect and dignity. 

 How does GUIDE help someone stay in their community longer? 

Most people want to age with fewer disruptions and remain in the place they call home.  We support aging in place by anticipating changes, coordinating care and standing alongside families during hospital stays, falls or other major transitions — so people can remain safely in their community longer.
 

When does GUIDE make the biggest difference? 

GUIDE often makes the greatest impact during moments that feel overwhelming, such as: 

• Sudden changes in behavior 

• Falls or medical scares 

• Emergency room or hospital visits 

• Caregiver burnout 

• Transitions between care settings 

During these moments, Dementia Care Navigators help caregivers and families understand what’s happening, coordinate next steps and feel supported rather than alone. 

GUIDE ELIGIBILITY & COST 

Who is eligible for the GUIDE program? 

Eligibility is confirmed through a Medicare-guided assessment process. A person may be eligible for GUIDE if they: 

• Have Traditional Medicare as primary payer (Parts A and B) 

• Have a diagnosis of dementia or another neurocognitive disorder 

• Are not currently enrolled in hospice 

• Are not living in a long-term nursing home 

Many people living in assisted living or memory care communities are still eligible. The term “long-term care facility” can be confusing, but it often refers to nursing homes. 

 The GUIDE program isn’t available for people enrolled in a Medicare Advantage plan through a private insurer. If your loved one has Medicare Advantage, we can help you understand whether switching to Traditional Medicare in the future might be an option and when that could make sense. Even if GUIDE isn’t available right now, we’re still happy to talk through other support options. 

How do I get started with Dementia Care Navigation? 

Enrollment begins with a conversation, not a commitment. First, our team connects with the caregiver to understand what’s going on, what’s been challenging, and where support might help. This conversation happens in a format and at a pace that works for the caregiver. 

 Next, Medicare requires a short caregiver questionnaire (about 20 questions). This assessment helps Medicare understand how caregiving is affecting them and a key step for determining eligibility for respite services. 

Then, the Dementia Care Navigator completes a comprehensive assessment with the patient. For most families, this happens in person and takes about 90 minutes. It looks at safety, environment, dementia stage, health-related needs and caregiver impact and is intentionally thorough, so care can be tailored appropriately. 

 Ongoing support begins after enrollment. Contact is often more frequent at the beginning as the Dementia Care Navigator gets to know the family and situation. Over time, many families prefer regular touchpoints — often monthly — with flexibility based on changing needs. 

Is this program really free?
Yes. The cost of GUIDE services is fully covered by Centers for Medicare & Medicaid Services (CMS) for people enrolled in Traditional Medicare. There is no added cost to patients or caregivers. 

Does this affect other Medicare benefits?
No. GUIDE services are designed to work alongside existing Medicare benefits and do not replace or reduce other covered care.  

How long can someone stay enrolled in GUIDE? 

GUIDE is not a short-term or crisis-only program. A person can continue receiving GUIDE services as long as they are eligible and enrolled in Traditional Medicare. Dementia care needs change over time, and GUIDE is designed to provide steady, ongoing support throughout the journey — adapting as situations evolve rather than ending after a set period. 

GETTING STARTED 

What’s the best next step for families? 

If you think this program could help your family, the next step is simply a conversation. We’re happy to meet your loved one, connect with community staff, and take time to understand your situation. Families choose how and how often they communicate with us — and often, the greatest relief comes from knowing someone else is there to help.  

You don’t have to navigate dementia alone. Fill out an enrollment interest form and a Bluestone team member will be in touch.