How to Start GUIDE with Mobile Medical

Dementia patient hugging caregiver

Getting Started with Mobile Medical’s GUIDE Program

Program initiation, what happens next, and typical timelines for setup

Caring for a loved one with dementia can feel like managing a dozen moving parts at once—medical needs, medications, appointments, safety concerns, and the emotional toll on caregivers. The CMS GUIDE Model (Guiding an Improved Dementia Experience) was created to make that journey more coordinated and more supported—especially for families providing unpaid care.

Mobile Medical participates in this model to help patients with dementia stay safely at home longer while giving caregivers real, ongoing help—not just a list of resources.

What the GUIDE Program is

The GUIDE Model is a voluntary, nationwide CMS model designed to improve dementia care through a standardized package of support for both the patient and their caregiver.

Services can include:

  • Care navigation and care coordination

  • 24/7 access to a support line for urgent questions

  • Caregiver training and education

  • Connections to community resources

  • Respite services (CMS describes respite support up to $2,500 annually for eligible patients/caregivers)

Mobile Medical’s GUIDE page also highlights personalized care plans and 24/7 access to care teams as core benefits for patients and caregivers.

Program initiation: how to start GUIDE with Mobile Medical

Starting GUIDE is meant to be straightforward. For Mobile Medical, the most direct first step is to submit the “Apply for GUIDE” form so the team can contact you.

Step 1: Request enrollment / express interest

  • Complete the GUIDE application form on the Mobile Medical website (or contact Mobile Medical directly by phone at 904-544-5581).

Step 2: Intake outreach from the GUIDE team
After you apply, a Mobile Medical team member will reach out to:

  • Confirm basic information

  • Learn about current needs and caregiver concerns

  • Begin scheduling the first assessment

Step 3: Confirm that the patient is appropriate for GUIDE
CMS notes that people with Medicare must have dementia and may be at any stage (mild, moderate, or severe). When first assessed, CMS relies on clinician attestation based on a comprehensive assessment (rather than requiring prior claims history with dementia diagnosis codes).

What happens next: GUIDE setup steps (after referral or application)

Once a patient is accepted, GUIDE generally follows a consistent, practical flow:

1) Comprehensive assessment

The GUIDE model centers on a comprehensive assessment to identify the patient’s needs and build an individualized plan.

This is where Mobile Medical’s team looks at things like:

  • Current medical conditions and medications

  • Safety risks and daily function

  • Behavioral symptoms and caregiver challenges

  • Available support systems and community resources 

2) Personalized care plan + navigation support

From there, the team develops a care plan and connects the patient/caregiver to ongoing navigation and coordination support. CMS describes this as coordinated dementia care that supports the needs of both the patient and the caregiver.

3) Caregiver education and support

GUIDE includes caregiver training/education and ongoing support—because caregiver wellbeing directly affects outcomes for the patient.

4) 24/7 support for urgent questions

Care doesn’t only happen Monday–Friday. CMS includes 24/7 access to a support line as a key component of the model. Mobile Medical also emphasizes around-the-clock access to care teams and navigators.

5) Respite coordination (when eligible)

Respite is designed to temporarily relieve qualifying caregivers and can include options such as in-home care or adult day programs, depending on availability and eligibility.

Typical timelines: how long does it take to get a patient set up?

Timelines can vary based on scheduling, patient complexity, and caregiver availability, but most families want a clear expectation of “what happens when.” Here’s a practical way to think about the onboarding process:

Within the first few days (after application):

  • Mobile Medical contacts the patient/caregiver

  • Intake questions are gathered

  • The initial assessment visit is scheduled

Within the first 1–2 weeks:

  • Comprehensive assessment is completed

  • Caregiver needs are identified

  • Support pathways start to take shape (education, navigation, resources)

Within weeks 2–4:

  • The care plan is active and communication routines are established

  • Caregiver education and ongoing support become consistent

  • 24/7 support access is reinforced (who to call, when to call, what’s urgent)

Ongoing:

  • Regular monitoring and coordination continue

  • Services can be adjusted as needs change

Ready to start?

If you’re caring for someone with dementia—or you’re a family member trying to reduce crisis-driven care—Mobile Medical’s GUIDE team can help you take the first step.


Learn more about the program: Mobile Medical GUIDE page

Apply for GUIDE