Dementia Care

People with Original Medicare and a diagnosis of dementia or other neuro-cognitive disorder are eligible. Those who are on hospice are not eligible.

Many people choose to enroll in dementia care navigation services when:

• Health or behaviors are changing, such as hospitalizations, medication challenges, wandering, agitation, or isolation.
• New medications or care transitions feel hard to manage.
• Care feels fragmented and it’s difficult to know who to contact or how to get updates.
• Caregiving feels overwhelming, exhausting, or hard to balance with daily life.
• You need extra support with daily activities, planning, or taking a break.
• You want more guidance to support your loved one’s comfort, happiness, and quality of life.
• You have questions, worries, or uncertainty about what to expect in the future.

Dementia Care Navigators are licensed nurses or social workers who provide 24/7 support to patients and caregivers, both through regular in-person visits and virtual support whenever it’s needed.

Embedded in the communities they serve, they regularly visit to listen, observe, and collaborate directly with staff.

Over time, they build strong, trusted relationships through consistent care, communication, and partnership. They can 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 locate and coordinate specialists 
• Identifying safety and environmental needs 
• Supporting equipment needs, such as adaptive or sensory tools 
• Supporting families during emergency room visits or hospital stays 

We start by connecting with you to understand your situation and where support may help — in a format and at a pace that works for you. As part of this step, Medicare requires a brief caregiver questionnaire (about 20 questions) to assess caregiver impact and determine eligibility for respite services.

Next, you’ll complete a comprehensive assessment. For most families, this happens in person and takes about 90 minutes. Your dementia care navigator will review safety, environment, stage of dementia, health needs, and caregiver strain. This thorough approach allows us to tailor care appropriately.

After enrollment, ongoing support begins. Contact is often more frequent at first as your care navigator gets to know your family, then settles into regular check-ins — often monthly — with flexibility as needs change.

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 often 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. 

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, whether that’s phone calls, email or the Bluestone Bridge — our secure communication tool. At minimum, caregivers are asked to: 

• Share information during conversations 
• Complete the required caregiver questionnaire 
• Stay connected in a way that feels manageable to them 

 Many caregivers live out of state or share responsibilities with siblings or other family members.

We work within your family’s structure and with patient or healthcare power of attorney permission, Dementia Care Navigators can include multiple caregivers in conversations, provide updates and help coordinate communication so everyone feels informed and supported. 

Respite care eligibility is determined using two standard assessments:

• Medicare’s caregiver assessment, and

• a dementia staging tool.
  

Together, these help us understand the needs of both the patient and the caregiver. Based on where a patient falls, some may qualify for respite support as part of the GUIDE Model.

If respite is appropriate, your Bluestone Dementia Care Navigator handles everything — placing the referral and coordinating care with our trusted partner, CareLinx, who manages staffing and scheduling.

Respite care is highly personalized and designed to support real, everyday needs. Families have used respite services for:

• Companionship and social visits

• Accompaniment to appointments, such as MRI visits

• Walks and light activity to encourage safe movement and exercise
  

The benefit includes $2,500 in respite services, which equals 19 units of four-hour shifts, and can be used in ways that best support both the patient and caregiver. Our goal is simple: flexible, meaningful support that fits your life — not a one-size-fits-all solution.

Yes. The cost of GUIDE services is fully covered by Centers for Medicare & Medicaid Services (CMS) for eligible people who are enrolled in Original Medicare.

There is no added cost to patients or caregivers. GUIDE services are designed to work alongside existing Medicare benefits and do not replace or reduce other covered care.