Every patient aligned to a GUIDE participant needs an initial comprehensive assessment, a follow-up assessment each year, and an extra reassessment whenever something changes that could affect their tier. The results go to CMS on the Patient Assessment and Alignment Form (PAAF), and they feed two of the model's five performance measures.
This guide explains what the assessment covers, when a reassessment is required, how PROMIS-10 and ZBI-22 data are collected, and how to keep your submissions on schedule.
What Is a GUIDE Comprehensive Assessment?
CMS's Performance Measurement Manual describes it as a required, multi-domain clinical evaluation. It does three jobs:
It determines the patient's model tier, which is based on dementia complexity, caregiver status and residence type.
It informs the care plan.
It supplies data for performance measurement.
The initial assessment happens as part of alignment, after the patient has been told about the model. Follow-up comprehensive assessments happen annually.
What Should the Assessment Cover?
The manual's appendix connecting care delivery to performance measures gives a useful picture of what CMS expects the assessment to include. It calls out these elements:
Medication reconciliation and review. At the initial assessment, CMS calls this the first opportunity to identify potentially inappropriate medications and address medication-related risks.
Behavioral health screening, screening for upstream drivers of health needs, and a home visit assessment. CMS says these help care teams understand and identify ways to maintain or improve quality of life.
A caregiver assessment. CMS describes it as a critical opportunity to assess the caregiver's knowledge, needs and social supports, along with their well-being, stress level, and ability and willingness to provide help.
Advance care planning. CMS says this helps align care with the patient's goals and reduces crisis-driven decisions that often lead to a nursing home, and it strongly encourages including caregivers.
CMS describes the appendix as a supportive reference and not a formal protocol or a complete list of requirements. The full care delivery requirements are in the GUIDE Participation Agreement.
When Is a Reassessment Required?
A reassessment is required when a participant becomes aware of a change that could affect the patient's tier, outside the annual schedule. The manual lists three triggers:
A change in the patient's dementia stage
A change in the caregiver's status or burden
A change in where the patient lives
Two details are easy to miss. A reassessment does not count as the annual comprehensive assessment, so you still owe the annual one. And when the caregiver or the level of caregiver burden changes, you have to administer the ZBI-22 again and submit the results. The PROMIS-10 is not required at a reassessment.
What Data Goes to CMS, and How?
Participants record assessment data in the PAAF and send it to CMS through the HDR application. Participants with FHIR-enabled EHRs can use a FHIR-based API instead.
The PAAF has worksheets for two surveys:
PROMIS-10, completed by the patient. CMS uses it for the Quality of Life for Patients Living with Dementia measure. It has physical and mental health sub-scales that are scored separately.
ZBI-22, completed by the caregiver. CMS uses this 22-item survey for the Caregiver-Reported Impact in Dementia measure. It is required for the caregivers identified in the PAAF, and CMS defines a caregiver as a relative or unpaid nonrelative who helps the patient with daily activities.
Required supplemental questions for each survey go in a separate PAA worksheet.
Timing: What Has to Happen When
Timing determines whether data counts toward your measures, so it is worth being precise.
The PROMIS-10 needs two data points. The quality of life measure requires two survey responses from the same patient, collected 12 months apart, plus or minus 60 days. That means the annual assessment needs to be scheduled with a window in mind.
The PAAF is due within 60 days. CMS expects it within 60 days of both initial alignment and each annual assessment.
There is a final submission window. For each performance year, the last day to submit data that counts is the end of August after the year closes. For PY 2025, which ran from July 2025 to June 2026, the window was July 1 to August 31, 2026. For PY 2026, it runs from July 1 to August 31, 2027.
Use the right template. For assessments tied to PY 2026, CMS says participants must use the PY 2026 PAAF template, and data submitted on earlier versions may not be accepted.
Why This Matters for Payment
The two survey-based measures carry six of the ten possible points in the performance-based adjustment for PY 2026. If data is late, incomplete or on the wrong template, you can lose that contribution. New Program Track participants in PY 2025 earned a +2 percent contribution to the adjustment by submitting PROMIS-10 data for at least 90 percent of aligned patients.
CMS only scores a measure if a participant reaches the minimum case count, which is 20 eligible patients for the survey measures, so a program with a small panel has little room for gaps. Our guide to the GUIDE performance-based adjustment explains how the measures translate into payment.
A Practical Checklist
Before the assessment: Confirm the patient is eligible and identify the caregiver by name.
During the assessment: Cover medication reconciliation, behavioral health, home environment and drivers of health, the caregiver assessment, and advance care planning. Administer the PROMIS-10 and the ZBI-22.
After the assessment: Enter the data on the current PAAF template and submit within 60 days.
Set the annual reminder early. Schedule the next assessment so the PROMIS-10 falls about 12 months after the first, within the 60-day tolerance.
Watch for triggers. Ask the care team to flag changes in dementia stage, caregiver status or burden, or residence, and reassess promptly. Remember to repeat the ZBI-22 when the caregiver or their burden changes.
Check submissions before the deadline. Don't wait until August to find gaps.
Where Elli Cares Fits
Many reassessment triggers show up between visits. A caregiver mentions they are struggling, a family member notes a change in routine, a move to a new setting is being discussed. Elli Cares gives care teams a place to see daily wellbeing check-ins, family observations and activity over time, so a change is more likely to reach the care navigator before the next scheduled assessment. Elli doesn't administer the PROMIS-10 or the ZBI-22, complete the PAAF, or replace a clinician's assessment. You can read more on our GUIDE page.
Frequently Asked Questions
What is a GUIDE comprehensive assessment?
It is a required, multi-domain clinical evaluation completed at alignment and then annually. CMS uses it to assign the patient's tier, inform the care plan and support performance measurement.
When is a GUIDE reassessment required?
When a participant becomes aware of a change in the patient's dementia stage, the caregiver's status or burden, or where the patient lives. A reassessment does not replace the annual comprehensive assessment.
How do participants submit assessment data to CMS?
Through the Patient Assessment and Alignment Form (PAAF), sent via the HDR application or, for participants with FHIR-enabled EHRs, a FHIR-based API.
How far apart should the two PROMIS-10 surveys be?
About 12 months, plus or minus 60 days, according to CMS's Performance Measurement Manual.
Is the ZBI-22 required at a reassessment?
Yes, when the caregiver or the level of caregiver burden has changed. The PROMIS-10 is not required at reassessments.
