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The Alzheimer’s and Dementia Care Program provides ongoing care for patients with a dementia diagnosis. Call 310-319-3222 to learn more about dementia care at UCLA Health.

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The Center for Medicare and Medicaid Services (CMS) introduced the Guiding an Improved Dementia Experience (GUIDE) Model, which is a voluntary nationwide Medicare model test that aims to support people with dementia and their unpaid caregivers. The model began on July 1, 2024, and will run for eight years. 

In July 2024, the UCLA Alzheimer’s and Dementia Care Program (UCLA ADC) began providing comprehensive dementia care through the GUIDE model. This model provides Medicare coverage for comprehensive, coordinated dementia care. It aims to improve the quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities. It will achieve these goals through Medicare payments for a comprehensive care coordination and care management package, caregiver education and support, and respite services. 

Persons living with dementia (PLWD) enrolled in the GUIDE model who have moderate or severe dementia will also have an in-home visit. They may be eligible for limited in-home or adult day care respite service benefits.  

To be eligible for the CMS GUIDE Model, the patient must meeting the following: 

  • Has a confirmed diagnosis of Alzheimer’s or other types of dementia 
  • Has Medicare Part A&B as primary insurance (not under a managed plan) 
  • Is not enrolled in a Special Needs Plan (SNP) or PACE (Program for All-Inclusive Care for the Elderly) 
  • Is not enrolled in Medicare hospice benefit  
  • Is not living in a long-term nursing home  
  • Lives within the UCLA ADC Program service area 
  1. A comprehensive appointment is scheduled by the ADC Program administrative team.  
  1. The patient/caregiver completes a required pre-visit questionnaire prior to the assessment.
  2. The comprehensive assessment is conducted with a Dementia Care Specialist. 
  1. We send information from the appointment to Medicare to determine benefits. 
  1. The patient and caregiver receive continued coordinated care from the ADC program. 

GUIDE Benefits

CMS requires GUIDE enrollees to have a in-home visit in cases of moderate or high complexity dementia and a telemedicine home visit for low complexity patients. A home visit is required for some patients within the program who meet criteria determined by Medicare. A home visit helps ensure that you and your caregiver get additional support and evaluate if any safety measures are recommended. 

The UCLA ADC program partners with home care agencies to perform the one-time home visit. The home care agency will contact you directly to arrange a time.   

During the home visit, we assess:   

  • The home environment  
  • How you function in your home, including performing your personal care tasks 
  • Other environmental, social and behavioral factors  

The home agency visitor will talk with you and walk around your home to evaluate safety and fall risk.   

We ask that the patient and caregiver be present for the home visit.  

Through GUIDE, Medicare offers a yearly amount for eligible GUIDE enrollees so caregivers can take a break when needed. Eligible UCLA ADC program GUIDE enrollees can receive respite services each year.  

Respite service support comes from local in-home respite providers and adult day centers. The UCLA ADC program partners with community-based organizations (CBOs) and home care agencies to provide these services. 

Patients enrolled in the GUIDE Model with moderate to high complexity dementia who have a caregiver are eligible for respite services. The respite services fund is available to eligible GUIDE enrollees after completing their initial visit and being aligned within the GUIDE Model. 

You can use respite service funds for in-home care or adult day services.  

Funds renew on July 1 yearly through the 8-year program. You cannot carry over unused funds to the following year.  

GUIDE FAQs

The care you and your loved one currently receive with the UCLA Alzheimer’s and Dementia Care (ADC) program will remain the same. You’ll continue comprehensive visits, as-needed follow-ups, and communication with your dementia care specialist and ADC team. Enrolling in the GUIDE model can provide you with additional benefits if you are eligible.  

We understand that personal circumstances may vary. We respect your right to decline participation in the GUIDE Model. GUIDE-eligible patients who decide not to participate cannot continue enrollment in the UCLA ADC program.  

If you change your mind and would like to re-enroll in GUIDE with the UCLA ADC program, a referral from your PCP would initiate the enrollment process. 

The UCLA ADC program will continue to enroll patients with all insurance types that UCLA Health accepts. The program will provide the same dementia care services if you are enrolled in the UCLA ADC program, regardless of your insurance. 

It’s required to offer for participation if you meet the eligibility requirements for the GUIDE Model. If you do not consent to a home visit, we can’t keep you enrolled in the program. We understand that personal circumstances may vary. We respect your right to privacy and your decision.  

We can’t provide a home visit if you don’t meet the eligibility requirements. 

Once we identify the need for respite services, the ADC program arranges for these services to begin with a home care agency or refers you to an adult day care center. The partner agency will contact you to schedule services. Once services are provided, the agency bills the UCLA ADC program, and we pay the agency using Medicare funds. You should not receive a bill from the home care agency. 

UCLA Health manages respite service funds for all eligible GUIDE enrollees. Funds are not given directly to the GUIDE enrollee. The UCLA ADC program manages available funds and payments to community partners.    

Only community-based organizations (CBOs) and home care agencies that have established partnerships with the UCLA ADC program can provide GUIDE respite services.   

GUIDE enrollees cannot use respite funds for their caregiver, In-Home Supportive Services (IHSS), or receive direct payments. The UCLA ADC program manages the respite funds and coordinates with the agencies to provide services.    

The respite fund is available for eligible GUIDE enrollees to use when needed. The respite fund has a yearly maximum and cannot carry over to another year. 

Regardless of your enrollment date, CMS considers a year beginning July 1. (For example, if you are enrolled on June 29, you have respite funds to use in two days before your funds are replenished on July 1.) Again, no carry-over funds are allowed. 

Yes, you will receive the same dementia care services if you are in the UCLA ADC program, regardless of your insurance. For those eligible for respite services, these are capped and matched to the GUIDE benefit.  

Please note, those under UCLA Medical Group- Medicare Advantage will be deferred to Carelinx for respite services.

No, if your respite funds run out before the end of the year, you are responsible for the costs of additional respite care. If appropriate, the UCLA ADC program team can provide recommendations on receiving these services, including qualifying for other benefits.  

External Referring Providers 

If you are a referring provider outside of UCLA Health, please find linked below additional information on eligibility requirements and required information to refer your patient to the ADC Program. Referral information can be faxed to 424-483-5850. 

Eligibility Information and Referring Requirements