Virginia Health Services launches the GUIDE program on July 1, 2025, to assist individuals with a dementia diagnosis and their caregivers who reside at home navigate care.
The GUIDE (Guiding an Improved Dementia Experience) Model was developed by The Centers for Medicare & Medicaid Services (CMS) and is designed to support individuals with dementia and their caregivers by providing expert guidance, essential resources and a personalized approach to managing care. Our VHS team aims to empower participants with the knowledge and tools needed to maintain independence, improve quality of life, and access the best care possible.
Our team hosted Open Houses to residents and their loved ones at our senior living communities — The Arbors Independent Living and The Hamilton and The Huntington Assisted Living — this week to explain the program, eligibility requirements, and how to get started.
What is GUIDE?
GUIDE is a palliative care program that offers guidance from a dementia diagnosis to end of life. The program pairs caregivers with a care navigator to assist with resources, (in some cases) offer respite, and take the stress off of caregivers.
VHS care navigator and social worker Julianne Wilson, LMSW, says they are in touch with caregivers every 90 days to a month, to every day. The program provides 24/7 on-call assistance.
“We have developed education and resources,” says Director of Social Work and Care Navigation Colleen Coleman, MSW. “The program has open enrollment over the next seven years.”
There is an evaluation process when individuals are first enrolled to assess home safety and address key needs. Caregiver education includes learning about dementia progression, behavioral symptoms, communication strategies, and how to handle daily care challenges.
The GUIDE care navigator also can help facilitate referrals to additional resources such as with VHS Home Health Care and VHS Rehabilitation.
“It’s not financial help … it’s whatever we can do so that you are not on your own,” Colleen says. “What you need is what we will be there for.”
Those enrolled stay in the program until they want to come out, or they go into long-term care or hospice, and there is not an income cutoff.
Am I eligible?
Patients must have a confirmed diagnosis of dementia — and our care navigation team can help secure that.
Other requirements:
- Be enrolled in Medicare Parts A and B (not Medicare Advantage)
- Reside in the community (i.e., living in a personal home, independent living or assisted living facility, excludes long-term care facility or nursing home).
- May not be enrolled in Hospice services or PACE (Program for All Inclusive care for the Elderly).
- Be willing to participate in the development and ongoing review of a personalized care plan.
Ready to learn more?
Our Virginia Health Services team is ready to help you navigate through this journey — you’re not alone!
You can connect with an enrollment specialist today to see if you’re eligible and apply. Call 757-223-1396 to get started.
Learn more about the CMS program: Learn more at cms.gov/priorities/innovation/innovation-models/guide
