September 20, 2026

GUIDE Caregiver Training and Support: What You Must Offer and Why It Affects Your Payment

A woman walking in a garden with her arm wrapped around an older woman

GUIDE requires participants to run a caregiver support program that includes caregiver skills training, dementia diagnosis information, support group services and ad hoc one-on-one support calls.

It affects payment in three ways: caregiver status helps determine a patient's tier, respite is only available to eligible patients who have a caregiver, and a caregiver-reported measure now counts toward your performance-based adjustment.

This guide sets out what CMS requires, which parts you can hand to a partner, how caregivers are counted and measured, and how to build an offering that holds up in practice. It is written for GUIDE program leads and care navigators. The requirements below come from CMS's request for applications. The Participation Agreement that participants sign sets the binding terms, so check it for any updates.

What Does CMS Require?

CMS's GUIDE page says participants must offer caregiver training and support services, as well as connections to community-based providers and resources, to reduce caregiver burden. The offering has to be based on the caregiver's needs and responsive to ongoing changes in those needs.

CMS's request for applications is more specific. It organizes the care delivery requirements under nine domains, and one of them is caregiver education and support. Under that domain, a participant must administer a caregiver support program that includes:

Caregiver skills training
Dementia diagnosis information
Support group services
Ad hoc one-on-one support calls

The request for applications says the program must be based on the caregiver's needs as identified through the comprehensive assessment, and it must respond to changes in those needs. The care plan also has to record the caregiver's options and preferences for education and support.

What Can You Hand to a Partner?

Not everything has to be delivered in-house. According to the request for applications:

You must provide directly: dementia diagnosis information and ad hoc one-on-one support calls with a member of the care team.
You may contract out: caregiver skills training, to a vendor or a community-based organization.
You may refer out: support group services, to an external provider.

The request for applications also says participants can partner with other organizations, including community-based organizations, to meet the care delivery requirements. CMS's partnership fact sheet gives an example of a family geriatrics practice that contracts with a national organization for caregiver education and support.

Because caregivers can call in, the 24/7 requirement matters here. The request for applications says the help line, which may be a third-party vendor outside working hours, must be available to receive ad hoc one-on-one support calls from the caregiver. CMS's model overview lists ongoing monitoring and support and 24/7 access to a support line as part of the caregiver services.

How Often Do You Have to Be in Touch?

The care navigator is the primary point of contact. The request for applications sets minimum contact frequencies by tier:

Low complexity dyad tier: at least quarterly
Moderate and high complexity dyad tiers: at least once a month
Low complexity individual tier (no caregiver): at least once a month
Moderate to high complexity individual tier (no caregiver): at least twice a month

Those figures come from the 2023 request for applications, so confirm the current minimums in your Participation Agreement.

Who Counts as a Caregiver?

The request for applications defines a caregiver as a relative, or an unpaid nonrelative, who assists the patient with activities of daily living or instrumental activities of daily living. The help may be episodic, daily or occasional.

That definition matters in practice. A neighbor who drives a patient to appointments and manages their pills may qualify, even if the family doesn't think of them as "the caregiver."

Patients without a caregiver can still receive GUIDE services. In that case, the request for applications says the caregiver assessment and the caregiver education and support domains don't apply, and the participant has to put additional safeguards into its care delivery.

How the Caregiver Piece Is Measured

CMS scores caregivers through the Caregiver-Reported Impact in Dementia measure, known as CID. According to CMS's Performance Measurement Manual:

CID uses the 22-item Zarit Burden Interview (ZBI-22), completed by the caregivers identified in the assessment form. Lower scores are better.
It contributed 0 percent to the payment adjustment in performance year 2025 because CMS needed more data to set a benchmark.
It counts from performance year 2026, with a potential adjustment of -1 percent to +3 percent. That makes it one of the two largest sources of upside in the adjustment.
When the manual was published in May 2026, CMS had not yet released the PY 2026 benchmark for this measure.

The ZBI-22 is required for every identified caregiver. If the caregiver or the level of caregiver burden changes, a reassessment is required, and you have to administer the ZBI-22 again.

How Caregivers Affect Payment Beyond the Measure

Tier assignment. According to CMS's manual, the initial assessment assigns each patient to a tier based on dementia complexity, caregiver status and residence type. The 2023 request for applications used ZBI scores to separate the moderate and high complexity tiers for patients with caregivers. A caregiver's presence and level of strain therefore affected the monthly payment level, so confirm the current tier criteria in CMS's payment methodology guidance.

What the payment covers. The request for applications says the monthly payment for tiers that include patients without a caregiver does not incorporate payment for caregiver education and support. For patients with caregivers, it does.

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Respite eligibility. CMS's manual says respite is available to patients in the moderate and high complexity tiers who have a caregiver. Without an identified caregiver, the family can't use it. Our guide to GUIDE respite services explains the annual cap.

The performance adjustment. Caregiver-reported results feed CID, which can add up to 3 percent to your monthly payment or subtract up to 1 percent from it.

What CMS's Manual Says Drives the Caregiver Measure

The manual includes an appendix linking care delivery to each measure. For CID, it points to activities such as the caregiver assessment, 24/7 access to the care team, ongoing care navigator contact, tailored skills training and support, and maximizing the respite benefit.

CMS describes this appendix as a supportive reference and not a formal protocol, and it doesn't promise a particular result.

It is still a useful checklist. If your caregiver offering doesn't include each of those activities, ask why.

Building an Offering

CMS gives participants room to choose how to deliver training and support, but the minimum program is clear. A workable offering usually includes:

A caregiver assessment at the start. Knowledge, needs, social supports, well-being, stress level, and ability and willingness to help all shape what training the caregiver needs.
Skills training tied to that assessment. Match content to what the caregiver is facing now, and revisit it as the dementia progresses. A vendor or community partner can deliver it if you track what each caregiver receives.
Dementia diagnosis information, given directly. Explain what the diagnosis means and what to expect, and repeat it as needs change.
Ad hoc one-on-one calls. Make sure caregivers know how to reach a member of the care team, and that your help line can take these calls at any hour.
Support group referrals. Keep a current list of groups, and follow up to see whether the caregiver attended.
Community connections. Referrals for meals, transportation and other needs the screening identifies.
Respite, offered early. Raise it when the caregiver qualifies, not after they are exhausted.

Why This Is Hard on the Caregiver's Side

The Alzheimer's Association's 2024 report found that 70 percent of dementia caregivers say coordinating care is stressful, two in three (66 percent) have difficulty finding resources and support for their own needs, and 35 percent said getting help to take a break was a challenge. The Alzheimer's Association's 2026 Facts and Figures report adds that unpaid dementia care carries a higher risk of emotional distress and negative mental and physical health outcomes.

Caregivers can't absorb another complicated program. Training that is short, matched to what they are dealing with and easy to reach is more likely to be used.

A Practical Checklist

Identify the caregiver early and record them accurately. Include people who help but aren't family.
Administer the ZBI-22 for every identified caregiver. Schedule the repeat when caregiver status or burden changes.
Confirm all four program components are in place. Skills training, diagnosis information, support groups and one-on-one calls, with clear ownership of who delivers each.
Decide what you build and what you buy. If you use a vendor or community partner, confirm how you will track what each caregiver receives.
Meet the contact minimums for each tier. Track them so nothing slips between assessments.
Screen for social needs and follow through. Make sure referrals are completed, not just listed.
Watch for CMS updates. Check for new manual versions and the PY 2026 benchmark for CID.

Where Elli Cares Fits

Caregiver support depends on knowing when a caregiver is struggling. Elli Cares gives families a shared care circle where relatives and friends can add observations, see the activity log and message the care team. That gives a care navigator a signal between scheduled contacts, so outreach can start earlier.

CMS requires the care navigator to be an individual and not artificial intelligence, and Elli isn't a care navigator. It doesn't deliver caregiver training, administer the ZBI-22, provide a 24/7 support line or replace a caregiver assessment. It supports the ongoing contact between your team and families. You can read more on our GUIDE page.

Frequently Asked Questions

What caregiver services does GUIDE require?

According to CMS's request for applications, participants must administer a caregiver support program that includes caregiver skills training, dementia diagnosis information, support group services and ad hoc one-on-one support calls. They must also offer connections to community-based providers and resources, and provide 24/7 access to a care team member or help line.

Can I use a vendor for caregiver training?

Yes. The request for applications says participants can contract with a vendor or community-based organization to provide caregiver skills training and can refer caregivers to external support groups. Participants must provide dementia diagnosis information and ad hoc support calls directly.

How does GUIDE measure caregiver burden?

Through the Caregiver-Reported Impact in Dementia measure, based on the 22-item Zarit Burden Interview completed by identified caregivers. It counts from performance year 2026, with a potential payment adjustment of -1 percent to +3 percent.

Who is a caregiver in GUIDE?

CMS defines a caregiver as a relative or unpaid nonrelative who helps the patient with activities of daily living or instrumental activities of daily living. The help can be episodic, daily or occasional.

Why does caregiver status affect payment?

It is one input to a patient's tier, it determines whether respite is available, and caregiver-reported results feed the CID measure that adjusts your monthly payment.

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