Johns Hopkins GUIDE: Charting the Course for Memory Care
Offering Evidence-Based Dementia Care Navigation to More Homes and Families Johns Hopkins Guiding an Improved Dementia Experience (GUIDE)
Care Coordination & Management
Respite Services
Caregiver Support & Education
This program supports our goal of keeping my husband at home where he is peaceful.
Caregiver*
Quality of Life at Home
The purpose of the GUIDE Model is to improve quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities and plan for the transition to the next phases of care.
- Comprehensive Assessment: Person with dementia and caregivers receive separate assessments to identify their needs and a home visit to assess safety.
- Care Plan: Care plans address goals, preferences, and needs, which helps them feel certain about next steps.
- 24/7 Access: Members can call their care team using a 24/7 helpline.
It is very reassuring to have visits with the Care Coordinator. It is such a blessing to know someone [who] understands and cares and would take all this time to help navigate uncharted territories. Our family is thankful indeed.
Caregiver*
- Ongoing Monitoring and Support: Care navigators provide long-term help to the person with dementia and caregivers so they can revisit their goals and needs at any time and are not left alone in the process.
- Referral & Support Coordination: The care navigator connects the person with dementia and their caregivers to community-based services and supports, such as home-delivered meals and transportation.
[The team] came to our home as I do not drive. They helped me realize that I wasn't the only person going through such a trying time. It's good to know that there was help out there.
Caregiver*
- Caregiver Support: Caregivers can take educational classes and respite services are available to benefit both the person with dementia and their caregivers, which helps relieve the burden of caregiving.
- Medication Management: The clinician reviews and reconciles medications as needed; care navigators provide tips to maintain the correct medication schedule.
- Care Coordination & Transition: The person with dementia receives timely referrals to specialists to address other health issues, such as diabetes, and the care navigators coordinate care with the specialist.
*Caregiver feedback collected as part of research study
Frequently Asked Questions
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Johns Hopkins GUIDE is a special program that helps older people who have Medicare. To join the program, the person must:
- Have a dementia diagnosis made by a medical care provider.
- Have Medicare Parts A and B. The person can also have Medicaid. The person cannot have “Medicare Advantage” plans.
- Live at home in the community or with family. The person cannot live in a nursing home.
- Not get help from Hospice.
- Not get help from PACE.
- Live in the Baltimore area, including Baltimore City, Baltimore County, and parts of Howard and Anne Arundel Counties.
- If you live outside of these areas, visit CMS to find programs near you.
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If you think you meet the GUIDE criteria (see question #1) and want to learn more, please call us at 667-306-9594 or email us at [email protected].
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The program will start on July 1, 2025, and will run for seven years.
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Yes. Johns Hopkins GUIDE program will provide education and coaching to primary caregivers. It teaches caregivers about memory loss and other symptoms related to memory disorders and thinking problems, what to expect and plan for in the future, and ways to help their loved ones. The program connects them to important resources and services that may benefit people with dementia. For example, it may help them find support groups where they can talk to others who care for people with dementia. Caregivers will be able to connect with their assigned “care navigator” for support and to help solve problems.
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Based on need, some people in the program will be eligible to receive about 80 hours of respite care each year when they are enrolled in the GUIDE program that is paid for by Medicare. Respite care is provided by professionals and gives the primary caregiver of the person with memory loss a temporary break. It allows the primary caregiver some time to rest, attend to personal matters, and recharge to prevent burnout. These short-term respite services can be delivered in:
- the patient's home;
- outside of the home at special center for adults during the day; or a
- residential facility that can care for someone all day and night (e.g. Assisted Living).
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The GUIDE program, including the care navigator services, is a benefit that is covered and paid for by Medicare for eligible Medicare beneficiaries. There is no out of pocket cost to eligible people with dementia who decide to enroll in the program.
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Care navigators will connect with the people in the program based on their personalized care plan. They will support people to help make sure everything in the care plan is working well. If there are any changes that need to be made or new problems that come up, the care navigators will work with the person to help solve them.
Meet the Interdisciplinary Team
GUIDE Clinical Directors
- Halima Amjad, MD, MPH, PhD
- Cynthia Fields, MD
- Kostas Lyketsos, MD
GUIDE Program Leadership and Staff
- Quincy Miles Samus, PhD
- Penny Ross, MPH - Program Manager
- Amya James, Care Navigator
GUIDE Affiliated Providers
- Inga Antonsdottir, DNP, PhD, AGNP-C
- Jee Bang, MD, MPH
- Haroon Burhanullah, MD
- Valerie T. Cotter, CRNP, DNP
- Seema Gulyani, CRNP, PhD
- Alexandra Goodman, NP
- Argye Elizabeth Hillis, MD
- Carol Wanjiru Keating, CRNP
- Justin Charles McArthur, MBBS
- Christopher B. Morrow, MD, MHS
- Andrea Nelson, RN, MSN
- Lolita Nidadavolu, MD, PhD
- Milap Anil Nowrangi, MD, MBE
- Esther Oh, MD, PhD
- Chiadi U. Onyike, MD
- Alex Pantelyat, MD
- John C. Probasco, MD
- Paul B. Rosenberg, MD
- Rebecca Rye, CRNP
- Maria Teresa Schmidt, DNP
- Mfon Umoh, MD, PhD
- Elizabeth Wise, MD
- Sevil Yasar, MD, PhD
Contact Us
Johns Hopkins GUIDE
5300 Alpha Commons Drive Alpha Commons Bldg., Fourth Floor Baltimore, MD 21224
Phone: 667-306-9594
Fax: 410-367-2255
Email: [email protected]