GUIDE Model: Care Navigator Training
The Medicare payment model, Guiding an Improved Dementia Experience (GUIDE), requires participants to train all Navigators and follow a standard approach to care management. The resources found in this learning pathway fulfill many of the requirements to help support GUIDE training and standardization. These resources are useful for the entire care team as well.
Background on Dementia
Learn how to discuss a dementia diagnosis with patients and caregivers in a way that is sensitive, clear, and supportive.
Learn techniques for supportive communication with people living with dementia, and their caregivers, to help them prepare for the challenges they may face as dementia progresses.
A framework for helping patients and caregivers understand the stages of dementia based on symptoms and behaviors. Center to Advance Palliative Care, 2024.
Overview of Assessments
Recommended validated cognitive assessment tools.
Recommended validated assessment tools for common comorbid conditions.
Validated tools for assessing caregiver health and well-being.
Screens for early dementia, which is often missed by common assessment tools such as the Mini-Mental Status Examination.
Person-Centered Planning
Learn best practices for building trust, eliciting patient values, and having patient-centered conversations about goals of care.
Learn how to facilitate future planning discussions with people living with dementia, and their caregivers.
Challenging Behaviors
Learn about the sources of behavioral symptoms for people living with dementia and how to respond to them.
Learn how to relieve suffering from common mood and sleep disturbances in order to improve quality of life for people living with dementia, and caregivers.
Functional Needs
Stratifies patients by level of functional ability. Like the PPS, the Karnofsky score can be used to predict survival.
Instrumental Activities of Daily Living (IADLs) span everyday tasks that many people with serious illness have difficulty with. This assessment tool will help teams identify needs that can be addressed with community supports
Tool to assess pain in cognitively impaired patients.
Advanced Care Planning
Learn about common health complications for people living with advanced dementia and how to support patients and caregivers.
Learn techniques to help patients and their caregivers plan for the future, both during the early stages of a serious illness and as a disease progresses.
Learn best practices for building trust, eliciting patient values, and having patient-centered conversations about goals of care.
In this on-demand webinar, the presenter shares cultural and religious beliefs among African Americans, which may discourage completion of or participation in ACP, and more.
Communication
This on-demand webinar discusses successfully collaborating to support people living with dementia and their caregivers.
This on-demand webinar, Bringing Comfort to People with Advanced Dementia, discusses how we can eliminate distress in patients with advanced Dementia.
Coordination of Medical Care and Community Services
Guidance for all clinicians on improving communication and ensuring smooth transitions of care for patients living with serious illness.
Identifies unmet need in housing, food, transportation, utilities, and safety. Developed by CMS for the Accountable Health Communities model, and recommended for Medicare and Medicaid beneficiaries.
Community-based resource locators and support services.
Supporting the Caregiver
Self-reported caregiver assessment.
Learn how to assess caregiver burden and connect caregivers with needed support systems.
Print or email this handout of caregiver resources for education and support.
Diversity in Dementia
Defines cultural humility and how it influences patient care and offers ways to provide culturally humble care.
Cultural assessment document with a mnemonic approach to improve communication with patients and families.
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