A GUIDE care navigator is the main point of contact for each aligned patient and caregiver, and every one of them can't be called every day. Deciding who to contact first is a daily judgment call. CMS doesn't prescribe how to make it, but its Performance Measurement Manual shows which kinds of contact feed which measures.
This guide sets out a working framework for prioritizing outreach, built from CMS's own care delivery guidance. It is a suggested approach, not a CMS requirement, and every care team should adapt it to its own patients and clinical judgment.
What GUIDE Expects From a Care Navigator
GUIDE requires the interdisciplinary care team to include a care navigator. According to CMS, participants assign each aligned patient and caregiver to a care navigator, who helps them reach clinical services and community-based non-clinical services and resources. Participants must also offer 24/7 access to a care team member or help line and provide caregiver training and support.
The manual describes the navigator as the caregiver's primary point of contact. It says ongoing contact directly shapes how caregivers experience GUIDE, and that consistent support helps prevent gaps in care and caregiver overwhelm. The relevant care delivery requirement is ongoing monitoring and support.
The Coordination Problem Is Real
The Alzheimer's Association's 2024 report found that 70 percent of dementia caregivers say coordinating care is stressful, and two in three have difficulty finding resources and support for their own needs. A care navigator sits at the point where those problems land.
The report doesn't say how many patients a navigator can safely manage, and CMS doesn't set a caseload limit in the sources reviewed for this article. What both do show is that the work is broad: it covers medications, transitions, caregiver strain, community services and planning.
A Framework: Five Signals That Move Someone Up the Call List
Each signal below maps to something CMS's manual identifies as a driver of performance or good care delivery.
1. A recent care transition. A hospital stay, emergency visit or move between care settings is a high-risk moment. The manual says medication reconciliation at transitions helps prevent errors and adverse drug events, and that person-centered coordination during transitions eases confusion and stress for caregivers. Contact after a transition should come first.
2. A medication change or concern. The claims-based high-risk medication measure looks at patients 67 and older with two or more fills of specified high-risk medications, including antipsychotics and benzodiazepines. The manual lists ongoing medication management, review and reconciliation as care delivery activities that affect it. A new prescription, a missed refill or a caregiver's worry about side effects is a reason to call.
3. A caregiver who may be struggling. CMS ties the caregiver-impact measure to the caregiver assessment, 24/7 access, ongoing navigator contact, tailored skills training and use of respite. Signs to watch for include a change in who the caregiver is, a caregiver mentioning exhaustion or isolation, or a reassessment trigger. A change in caregiver status or burden also requires a reassessment and a new ZBI-22.
4. A change in routine or function reported by the family or the patient. The manual describes navigators as checking in and anticipating needs. A note that a patient has stopped eating properly, is more confused in the evenings or has stopped attending an adult day program is worth a call before it becomes a crisis.
5. A benefit or deadline that hasn't been used. Respite is available to eligible patients, and the manual says care teams should proactively promote it. An eligible family that hasn't used respite, or a patient whose annual assessment or PROMIS-10 window is approaching, belongs on the list.
Turning the Signals Into a Weekly Routine
A simple structure can keep this manageable:
Start each week with the transitions list. Anyone who came home from a hospital or facility gets first call.
Review medication changes next. Check for new prescriptions, refill gaps and caregiver concerns.
Scan for caregiver strain. Look at recent notes, reassessment triggers and respite use.
Add anyone with a reported change. Include family observations and anything flagged since the last contact.
Finish with scheduling. List annual assessments due, PROMIS-10 windows and unused benefits.
Record what you did and why. A short note on each decision helps colleagues and improves the framework over time.
What the Framework Can't Do
This approach helps you sort a list. It doesn't diagnose anyone or predict who will need a hospital. Someone who looks stable on paper may be struggling, and someone flagged for a signal may be fine. Clinical judgment and the conversation itself remain the deciding factors.
The framework also depends on knowing what is happening between contacts. If the only information a navigator has is what came up on the last call, the list will be out of date within days.
Where Elli Cares Fits
Elli Cares is built for the between-visit problem. Care teams get a clinician dashboard, AI-generated summaries, daily wellbeing check-ins, medication reminders, an activity log and family observations, and the platform is designed to help teams see who may benefit from earlier outreach and prioritize those most in need of attention. Families can add observations and message the care team.
Elli doesn't diagnose conditions, doesn't provide emergency monitoring and doesn't replace clinical judgment or your 24/7 access line. It also doesn't guarantee better outcomes or take the place of CMS reporting. What it offers is a clearer picture between contacts, so the call list reflects the past week and not only the last conversation. You can read more on our GUIDE page.
Frequently Asked Questions
What does a GUIDE care navigator do?
According to CMS, a care navigator is assigned to each aligned patient and caregiver and helps them reach clinical services and community-based non-clinical services and resources. The manual describes the navigator as the caregiver's primary point of contact.
Does GUIDE require a care navigator?
Yes. CMS requires the interdisciplinary care team to include a care navigator and a clinician with dementia proficiency who can bill Medicare Part B evaluation and management services.
How do care navigators affect GUIDE performance measures?
CMS's Performance Measurement Manual links navigator contact to the caregiver-impact and nursing home measures, alongside other care delivery activities such as medication reconciliation, 24/7 access and respite. CMS describes these links as a supportive reference and not a formal protocol.
How can a care navigator decide who to call first?
CMS doesn't prescribe a method. A reasonable approach is to prioritize recent care transitions, medication changes or concerns, signs of caregiver strain, reported changes in routine or function, and unused benefits or approaching deadlines.
Does Elli Cares replace a care navigator?
No. Elli gives care navigators and clinicians between-visit information to support their decisions. It doesn't replace clinical judgment, emergency monitoring or the 24/7 access GUIDE requires.
