IN-HOME CARE

Bringing Dementia Care Home

Participating in the GUIDE program requires compassion & capability

By Rich Paul

In in-home care, dementia is not an abstract policy issue. It is a daily reality for families who are trying to preserve safety, dignity and connection while navigating one of the most complex care journeys in healthcare. When a loved one is diagnosed with dementia or Alzheimer’s disease, families are often left to answer urgent questions on their own: What support is available? How do we keep routines intact? How can we manage changing needs without losing sight of the person behind the diagnosis?

The industry has a responsibility to answer those questions with more than compassion. We must answer them with structure, consistency, innovation and scale.

When we learned about the Centers for Medicare & Medicaid Services’ (CMS) introduction of the Guiding an Improved Dementia Experience (GUIDE) model last year, our organization could clearly see alignment with our long-standing commitment to personalized, high-quality care for people living with Alzheimer’s disease and other dementils, while also advancing a broader vision for how dementia care should be delivered, coordinated and supported in the home.

What Participation Brings

GUIDE is a federal program that provides eligible Medicare beneficiaries with up to 76 hours of complimentary in-home dementia care each year at no out-of-pocket cost. Under the model, which CMS launched July 1, 2024, eligible individuals with a dementia diagnosis receive care coordination and family resources alongside hands-on caregiver support.

Here at SYNERGY HomeCare, we began participating in GUIDE in 2025, partnering with CMS-approved participant organizations, allowing us the opportunity to provide our eligible clients access to comprehensive, coordinated dementia care at no cost. The significance of GUIDE is not only what it offers today, but what it signals for the future: Dementia care must be more coordinated, more measurable and more responsive to the realities families face at home. The standards of care outlined in GUIDE are an important step toward formalizing dementia care and creating more advanced care coordination, care management and family caregiver education across traditional Medicare.

If the GUIDE pilot demonstrates that coordinated, home-based dementia support improves outcomes for individuals and families, the offerings available through traditional Medicare have the potential to become permanent benefits that people can always access. That is the kind of progress our industry should be working toward. Families should not have to rely on geography, private resources or chance to receive caregiver education, care navigation and respite during one of life’s most demanding situations.

Dementia care must be consistent in its standards and deeply personal in its delivery. A national organization like ours with a strong local presence can bring scale, training and accountability while still adapting to the needs of each household. That combination is essential when care needs can change quickly and family caregivers require support that is practical, timely and close to home.

Families Matter

GUIDE also brings to the surface a reality that has been underrecognized for too long: Dementia affects entire families, not only the person diagnosed. Family caregivers manage medications, appointments, meals, transportation, behavioral changes, safety risks, emotional strain and financial pressure. Many are doing this while working, raising children and caring for other relatives. Any serious effort to improve dementia care must recognize family caregivers as essential partners who need education, respite, navigation and sustained support.

For our organization, this work did not begin with GUIDE. In 2022, we launched a comprehensive memory care program that combined specialized caregiver training, client engagement tools and family resources. The program was built around an evidence-based, person-centered approach focused on the individual rather than the condition. We emphasized then, as we do now, that personalized memory care begins with understanding and appreciating each unique person—fostering normalcy, choice, purpose, belonging and security.

That philosophy matters because quality memory care in the home requires both compassion and capability. It requires caregivers who understand how cognitive decline can affect communication, behavior, daily routines and safety. It requires engagement that supports brain health, sensory connection and reminiscence. It requires practical tools to help reduce risks such as wandering and falls. And it requires family education so loved ones can better understand what is happening, respond with confidence and care for themselves along the way.

Dementia care must be more coordinated, more measurable & more responsive to the realities families face at home.

The Role of Caregivers

The GUIDE model reinforces this philosophy at a national level. Its focus on comprehensive, person-centered assessment and care planning, care navigation, caregiver education, 24/7 support and respite services reflects the direction dementia care must take. For homecare organizations, that shift validates the role we play on the front lines. Professional caregivers are often the people who notice subtle changes first, help preserve daily routines, support meaningful engagement and provide families with moments of relief.

Non-medical care also occupies a critical place between clinical care and daily life. Physicians, nurses, specialists and care navigators are essential, but the lived experience of dementia unfolds in kitchens, bedrooms, living rooms and neighborhoods. That is where a person may become disoriented, where a family member may become exhausted and where the right support can prevent a crisis.

If we want a more connected dementia care system, we must integrate medical and non-medical support in a way that envisions the whole person—and the whole caregiving ecosystem.

As the population ages, the demand for dementia-capable homecare will continue to grow. The question before our industry is whether we will treat that need as a specialty service on the margins or as a central responsibility of modern care. I believe it must be central. Families want their loved ones to remain safe, connected and respected at home for as long as possible. They also need a care model that acknowledges and works to alleviate the emotional and practical demands placed on caregivers.

From Episodic to Sustained

GUIDE creates momentum for that future. By elevating care coordination, care management, respite and caregiver education, the model helps move dementia care from episodic intervention toward sustained partnership.

Just as important, GUIDE gives the industry a framework to demonstrate that these supports should not be temporary or exceptional; they should become expected, reliable benefits within traditional Medicare. That is why participation, investment and execution matter so much during the current pilot period.

Involvement with GUIDE helps demonstrate why these services should remain accessible long after the eight-year pilot concludes. The needs of people living with dementia and their family caregivers deserve greater visibility, stronger coordination and more practical support.

As an industry, we should be measured by how well we help families sustain care with dignity, confidence and connection. That work starts where families live—and where so many people hope to remain: at home.