Stillwater, Minnesota – As the U.S. Population ages, the demand for specialized dementia care is rapidly increasing, placing a significant strain on healthcare systems and families. A new initiative, the Guiding an Improved Dementia Experience (GUIDE) program launched by the Centers for Medicare & Medicaid Services (CMS) in July 2024, aims to address this growing crisis. Bluestone Physician Services, a Stillwater-based clinic serving Minnesota, Wisconsin, and Florida, is among the first providers selected to participate, offering a promising model for improved care coordination and support for both patients and caregivers. This program is particularly vital as the number of Americans living with dementia is projected to reach nearly 14 million by 2060, driven by increasing lifespans.
For nearly two decades, Jessie Waks, senior vice president and head of primary care at Bluestone, has observed a concerning trend: more patients and their families are turning to senior living communities for care. Whereas the growth in these communities is a response to the need, Waks notes a critical gap in the system. “It’s not uncommon for a patient to produce it through the entire medical system, and get even all the way to memory care, and not have had a provider sit down with them and explain what dementia is, what to expect, what will happen as the disease progresses,” she says. This lack of clear communication and proactive support often leaves families feeling overwhelmed and ill-equipped to navigate the complexities of dementia care.
Addressing a Systemic Challenge
The GUIDE program directly responds to these systemic challenges. It provides funding for “care navigators” – dedicated professionals who work alongside physicians to provide individualized support to patients and their families. These navigators assist with everything from understanding the diagnosis and treatment options to coordinating appointments and accessing community resources. A key component of the program is the provision of up to $2,500 in respite benefits, offering temporary relief to unpaid caregivers, often family members, who shoulder a substantial burden.
Bluestone began offering GUIDE services in July 2025. The program has already enabled the clinic to expand its care team by 20 members, including the new care navigators. “GUIDE gave us another revenue stream to hire additional care team members and fill some of the gaps that even we aren’t able to meet just within primary care,” Waks explained. This additional staffing allows Bluestone’s physicians, nurse practitioners, and physician assistants to focus on the clinical aspects of care – medication management and medical assessments – while the navigators provide crucial emotional and logistical support.
The Importance of Home-Based Support
A central tenet of Bluestone’s approach, amplified by the GUIDE program, is keeping patients in their homes and communities for as long as possible. “Bringing a patient with dementia out of their home can cause increased confusion and chaos for them and really disrupt their lives,” Waks emphasizes. “We know that [home] is the best place for chronically ill patients, specifically [those] who have dementia.” The care navigators often make home visits, providing support to both the patient and their family, and helping to manage the challenges that can arise as the disease progresses. This proactive, in-home support is designed to prevent crises and improve the quality of life for everyone involved.
Navigating Uncertain Funding
Despite the promising start, the future of programs like GUIDE is not without uncertainty. The One Big Beautiful Bill Act, signed into law in July 2025, is projected to slash Medicare funding by $536 billion over the next decade. Waks acknowledges the potential impact of these cuts, stating, “While I’m unsure of how that would affect the GUIDE program, the program’s support is critical for patients like ours, who often cost the system quite a lot.” The financial stability of innovative programs like GUIDE will be crucial to sustaining improvements in dementia care.
Bluestone currently serves approximately 18,000 patients in primary care, spread across 600 assisted living and group homes in Minnesota, with a growing presence in Wisconsin and Florida. The clinic employs around 600 staff members dedicated to providing comprehensive care to this vulnerable population. The GUIDE program represents a significant investment in their ability to deliver that care effectively.
Dementia is a complex and challenging condition, and there is no single solution. But, initiatives like the GUIDE program, with its focus on coordinated care, caregiver support, and keeping patients in their communities, offer a vital step forward in addressing this growing public health crisis. The success of Bluestone’s implementation of the program will likely serve as a model for other healthcare providers across the country.
The Centers for Medicare & Medicaid Services will continue to evaluate the GUIDE program’s effectiveness over the next eight years. Updates on the program’s progress and findings will be available on the CMS website.
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