Published: February 5, 2026

If you're already delivering care through CMS's GUIDE Model, you know the day-to-day reality: managing Care Navigator caseloads, coordinating respite services, tracking 180-day reassessments, and ensuring you're capturing the quality measures that drive your performance adjustments.

This guide is for you—the organizations already in the trenches of GUIDE delivery. Here's how to optimize your Healthie setup to streamline GUIDE workflows, maximize your DCMP payments, and reduce administrative burden.

The Three Biggest Workflow Challenges (And How to Solve Them)

Based on conversations with active GUIDE participants, here are the operational pain points we hear most—and how Healthie customers are addressing them.

Challenge 1: Keeping Track of 180-Day Reassessments

The problem: Patients need reassessment every 180 days when their condition changes, and missing these windows affects payment tiers. Manual tracking in spreadsheets breaks down as caseloads grow.

The solution in Healthie:

Set up automated reminders:

• Create a custom metric called "Last GUIDE Reassessment Date"
• Use workflow automations to trigger Care Navigator tasks at 160 days (20-day warning)
• Tag patients approaching reassessment windows with "GUIDE-Reassessment Due"

Build assessment tracking into your Care Navigator dashboard:

• Use saved filters to create "Reassessments Due This Month" view
• Include last assessment date in patient profile overview
• Set up weekly reports showing upcoming reassessments

Pro tip from participants: Schedule reassessments slightly early (at 170 days) to build in buffer for patient availability and ensure you don't miss the 180-day window.

Challenge 2: Documenting Care Navigator Activities for CMS Reporting

The problem: CMS requires detailed reporting on Care Navigator activities, but charting every phone call, community resource connection, and caregiver touchpoint is time-consuming.

The solution in Healthie:

Create Care Navigator-specific charting templates:

• Build templates for common activities: caregiver check-ins, community resource referrals, crisis line follow-ups, respite coordination
• Include required data points: activity type, duration, beneficiary/caregiver involved, outcome
• Use charting macros for frequently documented scenarios

Track activities through structured data fields:

• Add custom fields to chart notes: "Activity Type," "Community Resource Connected," "Respite Service Coordinated"
• This makes it easier to generate reports for CMS HDR submission

Document community resource connections systematically:

• Maintain a resource library in Programs feature
• When connecting patients to resources, document which specific resource, when, and follow-up plan
• Use tags like "Transportation-Referred," "Meal-Program-Connected" for easy filtering

Pro tip from participants: Care Navigators should spend 5 minutes at end of each day doing "batch charting" for brief touchpoints rather than documenting in real-time. Template-based notes make this quick.

Challenge 3: Managing Caregiver Engagement Separately from Patient Care

The problem: GUIDE requires tracking caregiver burden, education, and support services—but caregivers aren't technically patients in your EHR.

The solution in Healthie:

Use Related Contacts strategically:

• Add caregivers as related contacts on patient profiles
• Create custom relationship types: "Primary Caregiver," "Secondary Caregiver," "Caregiver-Respite Recipient"
• Document caregiver burden scores and needs in patient chart with clear "Caregiver" section headers

Build caregiver education tracking into your workflow:

• Create a Program specifically for GUIDE caregiver education
• Modules might include: Understanding Dementia Progression, Managing Behavioral Symptoms, Self-Care for Caregivers, Accessing Community Resources
• Track completion status for CMS reporting
• Use secure messaging to send educational materials directly to caregivers

Track respite services systematically:

• Create a custom form called "Respite Service Coordination Log"
• Document: date requested, service type (in-home/adult day/facility), provider, hours used, caregiver feedback
• Track against $2,500 annual cap per patient

Pro tip from participants: Schedule quarterly "caregiver-only" check-ins (phone or virtual) to assess burden and discuss respite needs proactively, rather than waiting for crisis situations.

Maximizing Your DCMP: Quality Measure Optimization

Your DCMP payments are performance-adjusted based on quality measures. Here's how to ensure you're capturing what matters:

High-Risk Medication Tracking

In Healthie:

• Maintain complete medication lists for all aligned patients
• Create a "High-Risk Medications" tag or custom field
• Flag anticholinergics, benzodiazepines, antipsychotics, and other high-risk medications
• Set up quarterly medication reviews as recurring appointments

Best practice: Have your dementia-proficient clinician review medication lists quarterly, not just at annual comprehensive assessment.

Beneficiary Quality of Life Measurement

In Healthie:

• Use validated QOL tools as custom forms
• Administer at baseline, 6 months, and annually
• Track scores in Metrics to monitor trends
• Include QOL discussion in care plan reviews

Caregiver Burden Assessment

In Healthie:

• Build Zarit Burden Interview or similar validated tool as scored form
• Administer at same intervals as QOL assessments
• Link caregiver burden scores to respite service utilization
• Flag high-burden caregivers for proactive outreach

Pro tip from participants: When caregiver burden scores increase, immediately discuss respite options rather than waiting for caregiver to request help. Proactive respite coordination improves outcomes and reduces crisis situations.

Billing & Claims Management for GUIDE

Using GUIDE-Specific G-Codes Correctly

In Healthie:

• Configure insurance billing to include GUIDE G-codes
• Create separate claim templates for DCMP vs. respite services
• Track GUIDE claims separately from other Medicare billing
• Monitor claim acceptance rates and denials

Common billing mistakes to avoid:

• Billing DCMP for patients not yet aligned through HDR
• Submitting claims before completing initial comprehensive assessment
• Forgetting to update tier when patient status changes (disease progression or caregiver status)
• Billing respite services over $2,500 annual cap

Revenue Tracking & Forecasting

In Healthie:

• Use reporting and analytics to track GUIDE revenue by month
• Create custom reports showing: aligned patients by tier, DCMP revenue vs. performance adjustments, respite services utilization
• Monitor alignment trends (new enrollments vs. unalignments)

Financial planning consideration: Remember that performance adjustments to DCMP can take 6+ months to show up. Budget conservatively in first year based on base DCMP rates, treat performance bonuses as upside.

Streamlining Your HDR Reporting Workflow

PAAF Submission Process

CMS requires Patient Assessment and Alignment Forms (PAAFs) submitted through the Health Data Repository (HDR) application.

Workflow efficiency tips:

1. Standardize your assessment documentation:

• Build Healthie forms that mirror PAAF required fields exactly
• This makes it easy to copy data from Healthie into HDR portal
• Consider having Care Navigator complete initial data entry in Healthie, then have admin staff transfer to HDR

2. Create a PAAF submission checklist:

• Initial comprehensive assessment completed
• Disease stage determined
• Caregiver status documented
• All required fields captured
• Patient consent on file
• Clinician review completed

3. Batch your HDR submissions:

• Designate specific times (e.g., Monday/Thursday afternoons) for HDR data entry
• This is more efficient than logging in for each individual patient
• Maintain a "Pending HDR Submission" tag in Healthie to queue patients

Pro tip from participants: Create a "GUIDE Data Collection Checklist" that Care Navigators complete before scheduling comprehensive assessments. This ensures you have all information needed for HDR submission before the assessment appointment happens.

Handling Common GUIDE Scenarios

When Patients Want to Unalign

Process in Healthie:

• Document reason for unalignment in chart note
• Complete unalignment form in patient record
• Submit unalignment PAAF through HDR
• Update patient tags/status in Healthie immediately
• Stop billing DCMP after unalignment date

Tip: Exit interviews with unaligning patients provide valuable feedback for program improvement.

When Disease Progression Changes Payment Tier

Process in Healthie:

• Document disease progression in chart note with specific clinical observations
• Complete reassessment (can be done outside regular 180-day cycle if condition changes significantly)
• Update tier in Healthie patient profile
• Submit updated PAAF to HDR
• Adjust billing for new tier moving forward

Tip: Monitor for "tier change triggers" like new behavioral symptoms, ADL decline, caregiver stress increase—these may justify reassessment and tier adjustment before the 180-day mark.

When Caregivers Need Urgent Respite

Process in Healthie:

• Document caregiver crisis or burnout in chart
• Check respite services utilized year-to-date (ensure under $2,500 cap)
• Coordinate with respite provider (in-home agency, adult day center, or facility)
• Document respite arrangement: provider, dates, hours, cost
• Follow up with caregiver within 48 hours of respite period end
• Track respite satisfaction and caregiver burden change

Tip: Build relationships with 2-3 respite providers in each service area so you have options when urgent needs arise. Having backup providers prevents delays.

Team Collaboration Best Practices

Care Team Huddles

Weekly Care Navigator huddles:

• Review high-risk patients
• Discuss reassessments due
• Share community resource finds
• Troubleshoot challenging caregiver situations

In Healthie:

• Create saved filters for "GUIDE High Priority" patients
• Use internal messaging for case consultations between Care Navigators and dementia-proficient clinicians
• Document team decisions in patient charts with "Team Discussion" note type

PCP Communication

Systematic PCP updates:

• Care initiation summary (within 30 days of alignment)
• Significant clinical changes
• Quarterly care plan updates
• Care completion summary (when patient unaligns or passes away)

In Healthie:

• Create PCP communication templates for each scenario
• Generate summaries from patient chart data
• Use secure messaging or fax for transmission
• Document all PCP communications in patient chart

Looking Ahead: GUIDE Program Sustainability

Preparing for Performance Year 2

As you move beyond your first year:

• Analyze your Year 1 quality measure performance
• Identify gaps in documentation or care delivery
• Adjust workflows based on lessons learned
• Invest in training for areas where you fell short

Building for Scale

If your GUIDE program is growing:

• Standardize onboarding for new Care Navigators using Healthie training Programs
• Create role-specific playbooks (Care Navigator Playbook, Clinician GUIDE Reference)
• Build dashboards showing program-level metrics (total aligned patients, tier distribution, revenue)
• Consider hiring dedicated GUIDE program coordinator to manage HDR reporting

Upcoming Considerations

2026-2027:

• CMS may release updated quality measures or payment methodology
• Monitor GUIDE Model updates via CMS listserv
• Attend CMS technical assistance sessions for participants
• Connect with other GUIDE participants to share best practices

Resources for GUIDE Participants

CMS Support:

• Email: GUIDEModelTeam@cms.hhs.gov
• GUIDE FAQs
• Payment Methodology Paper (PDF)

Healthie Support:

• Contact your Customer Success Manager
• Healthie Help Center
• Submit feature requests via your CSM for GUIDE-specific workflow improvements

Questions about optimizing your GUIDE workflows in Healthie? Contact our team—we're working with multiple GUIDE participants and can share implementation patterns that work.

About Healthie: Healthie powers healthcare outside the hospital. Our EHR, telehealth, and patient engagement platform supports over 45,000 clinicians delivering longitudinal, collaborative care to 17+ million patient lives. From behavioral health to nutrition to chronic disease management to dementia care, Healthie is the infrastructure for value-based care at scale.

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