CU partners with Medicare to expand services for patients with dementia and their caregivers

Patients with dementia who have Medicare may be eligible to access additional support services, including access to a 24/7 support line and respite care, at no extra cost thanks to a federal initiative that is a partnership between the University of Colorado Division of Geriatric Medicine, CU Medicine, and the UCHealth Seniors Clinic.

For the first time, the Centers for Medicare and Medicaid Services is funding a dementia care management model that aims to better support patients and their caregivers, and the federal agency has partnered with health care professionals in CU Medicine to deliver care under the new model. 

The model, called the Guiding an Improved Dementia Experience (GUIDE) Model, launched this summer. It will test an alternative health care payment and service delivery model system over an eight-year period. GUIDE is a nationwide initiative that involves 390 participating partner organizations, including CU. Each of these organizations will offer a dementia care program to support patients with Medicare — no copay required.

Geriatrician and palliative care physician Hillary Lum, MD, PhD, who serves as medical director and a GUIDE practitioner for CU’s program, highlighted the value of this innovative model during a recent CU Department of Medicine Grand Rounds presentation. 

“The focus is to improve quality of life for people living with dementia, to enable them to remain living in their home and communities, and importantly, to provide caregiver training, education, support, and reduce the strain on unpaid caregivers,” said Lum, an associate professor and associate division head of geriatric medicine in the CU Department of Medicine. 

The need for patient and caregiver support 

Dementia is an umbrella term for when a person experiences cognitive decline due to a progressive neurodegenerative illness that causes them to need assistance with daily life. It is caused by damage to brain cells, hindering the cells’ ability to communicate with each other and leading to abnormal brain function. There are several types of dementia, with the most common type being Alzheimer’s disease.  

The number of Americans living with dementia is projected to increase from an estimated 6.7 million in 2023 to nearly 14 million by 2060, according to the Centers for Medicare and Medicaid Services. As of 2024, in Colorado, an estimated 90,800 people aged 65 and older have Alzheimer’s disease, according to the Colorado Department of Public Health and Environment.  

The risk of dementia is twice as high among individuals from Black or African American backgrounds compared to individuals who are white, Lum said. The risk is 1.5 times as high for people from Hispanic, Chicano, or Latine backgrounds. Data has also indicated that about one in three American Indian and Alaska Native elders will be diagnosed with dementia during the next 20 years.

“These populations are disproportionately bearing the burden of dementia diagnoses. There is an important need for community resources and caregiver support,” she said. 

Despite the growing prevalence of dementia, many people with dementia have traditionally not consistently received high-quality, coordinated care. This results in poorer health outcomes, including high rates of hospitalization and emergency department visits. 

As a patient’s dementia progresses, the potential safety and health risks that a patient faces can increase, such as the patient not taking the proper amount of medicine, being unable to cook for oneself, or wandering alone at night. Because of these risks, many patients need the help of caregivers, who often end up being family members or friends of the patient, Lum explained.  

“Specific to Alzheimer’s, one in three dementia caregivers said that their health has gotten worse in the past year,” Lum said.  

More than 11 million people served as an unpaid caregiver to someone with Alzheimer’s or another form of dementia in 2023, according to the Alzheimer’s Association. 

“Their health and well-being matter, too. By ensuring they take care of themselves, they will be better equipped to provide care to their loved ones,” said the Colorado Alzheimer’s Disease and Related Dementias State Plan.

Improving dementia care — from 24/7 support lines to care navigators 

Typically, patients with dementia and their caregivers have felt alone as they navigated the progression of dementia and challenges that come with it. The GUIDE Model aims to change that by offering a package of services to support both patients and their caregivers.  

These services include a comprehensive dementia assessment and care plan, 24/7 access to a support line for patients and caregivers to contact and get advice, a home visit to identify safety risks, referrals to community services, medication review, caregiver skills training, and respite services to give caregivers a temporary break from their responsibilities.  

Across the country, nearly 400 organizations, including CU, have committed to delivering the GUIDE model to eligible patients and their caregivers through interdisciplinary teams, which include a dementia care navigator. Care navigators are trained to help people with dementia and their caregivers by helping find ways to improve home safety, simplify managing medications, connect people with legal and financial resources, provide emotional support, and more.  

The CU GUIDE Dementia Program consists of a team of six: Lum, three care navigators — Jessica Cassidy, LMSW, Evelyn Romeo, and Beth Kaufman, MA, LPC, MT-BC — Adreanne Tatro, MM MT-BC, the clinical program manager and care navigator, and Alexandra Marcus, LSW, the clinical administrator. The team aims to support patients and their caregivers who have traditional Medicare and desire to join the GUIDE program through UCHealth.  

“There are no copays with this, which is a huge advantage for patients. It’s integrated and covered by their Medicare insurance,” Lum said. “They continue receiving their current care through primary care and neurology care, and we come alongside with dementia navigation.” 

As of November 2024, CU has enrolled 22 patients and their caregivers so far in its GUIDE program and has received more than 60 referrals. Although early, Lum and her colleagues have already seen the value of this program.  

For instance, a caregiver wrote in an email to one of CU’s dementia care navigators: “The reality is that my conversations with you were like a therapy session for me … I felt like I not only had a counselor but a friend as well who I could speak with, and that was very important to me as a caregiver.” 

“We know this is complicated,” Lum said, reflecting on the challenges dementia patients and their caregivers face. “This program is an opportunity to have a friend on the inside who can help.”