You can join the GUIDE Model if all of these apply:

• You have Medicare Parts A and B as your main insurance.
• You live in the program’s service area.
• You have a dementia diagnosis that qualifies.
• You are NOT in a Medicare Advantage plan.
• You are NOT part of a Program for All-Inclusive Care for the Elderly (PACE).
• You are NOT in hospice care.
• You do NOT live in a long-term nursing home.

Dementia is a condition that makes it hard for a person to think, remember, or solve problems. It can also change the way they act or communicate. Dementia happens when parts of the brain are damaged, and it gets worse over time. It is common in older adults, but it is not a normal part of aging.

Other Ways Dementia is known as:

• Memory Loss
• Senility
• "Losing their mind"
• "Old-timers’ disease"

The GUIDE Model offers free services to patients who are enrolled. To join, patients must first complete a full assessment with the GUIDE care team and get approval from Medicare.

This assessment includes questions and tests to check memory, daily activities, dementia stage, emotional and social needs, future care planning, and the needs of the patient and their caregiver (if they have one).

Once enrolled, patients and caregivers can get these services:

• Home Visits: A GUIDE clinician visits your home to assess your living space for safety and support, especially for patients with more complex needs.
• Personalized Care Plan: A care plan is created based on the patient’s dementia diagnosis, personal goals, and needs to improve their quality of life.
• 24/7 Support: Access to a phone line for help and guidance at any time, day or night.
• Regular Check-ins: The GUIDE care team will call regularly to check on the patient and provide ongoing support.
• Care Coordination: Help connecting with your current healthcare team and navigating other parts of the healthcare system.
• Referrals for Services: Assistance in finding and connecting with helpful services, like home care, modifications to make your home safer, or other community resources.
• Medication Management: Help reviewing and managing medications to make sure they are safe and effective.
• Caregiver Support: Education and help for caregivers based on their needs, identified through a caregiver assessment.
• Respite Care: For caregivers of patients with more complex needs, this gives them a break to focus on their own well-being.

Respite services provide temporary supervised care to a loved one either in-home, in an adult day center, or in a facility that can provide 24-hour care. This allows caregivers to take a break from taking care of someone with dementia by giving them time to rest, take care of their own needs, or have time to relax.

• Fill out the referral form [link]
• Email the following information to EssenGuideCare@essenmed.com.
• Patient’s name, Date of Birth, Address, and Phone number
• Patient’s Medicare Number and email address
• Name, practice, and phone number of patient’s primary care provider or dementia-diagnosing provider
• Unpaid Caregiver details (if applicable): Caregiver’s name, phone number, email, and whether they live with the patient.
• Healthcare Proxy’s contact information (if different from Caregiver)
• Call 347.202.6250 to provide the above information (please be sure to have in front of you when you call).

• If you haven’t completed one in the last 4 months, an Essen Provider will schedule Comprehensive Cognitive Assessment to confirm qualification in the program.
• An Essen team member will contact the caregiver to complete a “Caregiver Burden Assessment” in order to determine which resources can best support your caregivers.
• Our enrollment team will contact the patient or their proxy for a program enrollment / consent form.
• Once enrolled, you will receive an in-person home visit from a provider to develop a personalized, interdisciplinary care plan.

A caregiver is a family member or unpaid helper who supports the patient with daily tasks. This help can happen every day, sometimes, or only once in a while, depending on what the patient needs.

Caregivers don’t have to live with the patient, but they should assist with activities like:

• Getting dressed
• Bathing
• Eating
• Preparing meals
• Moving around
• Using the bathroom
• Getting in and out of a bed or chair

Caregivers can access special services to help them, including:

• Training in caregiving skills.
• Education about dementia and the patient’s diagnosis.
• Support groups to connect with other caregivers.
• One-on-one support calls.
• Lessons on important topics like self-care and well-being.
• Help finding community resources.
• Respite care (time off from caregiving)- if they qualify

• Complete Care: We help with all the needs of people living with dementia and their caregivers.
• Teamwork: We work with different care providers to make sure everything is connected.
• Support: We give caregivers helpful tips, tools, and resources.
• Easy Access: We make it simple to get the care and help you need.