GUIDE requires home care agencies to track specific Medicare data for every participating client, including dementia stage and diagnosis, Medicare enrollment status, beneficiary number, sociodemographic information, and caregiver support needs. Each client's profile should include a participation flag, structured Medicare fields, and a documented link to the certified partner managing their GUIDE coordination.

CMS's GUIDE model funds comprehensive dementia care at home, including care planning, caregiver training, 24/7 care navigation, and community resource connections for Medicare beneficiaries with dementia. It pays certified organizations a per-beneficiary-per-month fee, opening a new referral channel for private-duty home care agencies that partner with those certified providers to deliver in-home support.