Medical Specialties
Help Social Workers Guide Families Through Enrollment.
Before dementia care support can begin, families are asked to share health, social, and caregiving information. Gathering it usually takes appointments, phone calls, and paper forms.
PATHS helps healthcare organizations turn social work expertise into guided family journeys, giving caregivers clear steps while giving social workers visibility into what has been completed, understood, and signed.
Enrollment Happens at the Kitchen Table, Not Only in the Office.
Families caring for someone with dementia are asked to complete several forms before support begins. Every hour a social worker spends collecting and retyping answers is an hour not spent helping families.
7.2M1
Americans age 65 and older living with Alzheimer's dementia
~12M1
Family members and other unpaid caregivers of people living with dementia
19.2B1
Hours of unpaid dementia care provided in 2024
The Problem
An estimated 7.2 million Americans age 65 and older live with Alzheimer's dementia, supported by nearly 12 million family members and other unpaid caregivers. In 2024 those caregivers provided about 19.2 billion hours of unpaid care, valued at about $413 billion.1
The Cost to Care Teams
Medicare's GUIDE Model, launched July 1, 2024 for an eight-year run, supports dementia care navigation, caregiver training, and respite. Enrollment begins with information gathering, including assessments of the person living with dementia and of the caregiver's needs and strain. When intake happens in person or by phone, social workers schedule visits, walk families through each form, and retype answers into records.2,3,4,5,6
What Better Support Does
At one hospital using a PATHS GUIDE enrollment Path, families finish in about 9 minutes, based on PATHS timestamps. The hospital reports saving about 45 minutes of social worker time on each GUIDE submission to CMS by removing scheduling, in-person paperwork, and retyping. This is one hospital's experience, not a controlled study. Each organization supplies its own time and cost assumptions.7
Sources
- 1.Alzheimer's Association. 2025 Alzheimer's Disease Facts and Figures. Alzheimer's & Dementia 2025;21(4).
- 2.Centers for Medicare & Medicaid Services. Guiding an Improved Dementia Experience (GUIDE) Model. cms.gov.
- 3.Centers for Medicare & Medicaid Services. GUIDE Model Frequently Asked Questions. cms.gov.
- 4.National Association of Community Health Centers. PRAPARE: Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences.
- 5.HealthMeasures. PROMIS Global Health (PROMIS-10).
- 6.Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: correlates of feelings of burden. The Gerontologist 1980;20(6):649-655.
- 7.PATHS completion timestamps and hospital-reported time savings.
Every Need Pulls a Different Thread.
Food, housing, disability, dementia care, disaster relief. Each program has its own forms, rules, and signatures, and families rarely need just one.
14 programs. Each with its own forms. One family.
- Dad's memory is slipping. CMS GUIDE, Medicare, Rx Extra Help, Rep Payee
- Lost hours at work. SNAP Food Aid, TANF Cash Aid, Energy Assistance, Medicaid
- Can't work after the injury. Disability Benefits, Student Loan Relief
- Rent went up again. Housing Voucher
- The storm hit the house. FEMA Disaster Aid
- Caring for a veteran at home. VA Disability, VA Caregiver Support
One guided Path at a time.
- Social worker can submit
- Family signs or verifies
Illustrative. Representative rules and forms vary by state and program.
Social workers have a critical responsibility to prepare families for what comes next. But once families leave the office, how do we know they're ready?
Did they complete every required form? Do they understand what the program offers? Have they signed what they need to sign? Where do they need a social worker's help?
Gathering information is essential. Knowing what families completed, and where they got stuck, lets social workers spend their time where it matters most.
Social Work: From Professional Expertise to Guided Family Journeys.
Understand
Education and knowledge
Help caregivers understand the program, what enrollment involves, and why each form matters.
Take Action
Tasks, decisions, follow-through
Guide caregivers through each required form at home, on their phone, in their own time.
Manage Care
Forms, signatures, next steps
Keep enrollment forms, signatures, and next steps together in one journey.
Demonstrate
Assessments and engagement evidence
Show social workers what was completed and signed, and where follow-up is needed.
Meet Lorraine.She Starts the CMS GUIDE Enrollment Path.
Follow Lorraine, who cares for her father, Harold, through an illustrative nine-Step Path. A GUIDE program could use this structure to explain enrollment, collect each required form at home, and hand the results to its social work team.
The Steps alternate a short video with the form it introduces, mirroring the live GUIDE enrollment Path:
Illustrative person (AI-generated). Illustrative educational Path. Completing the Path does not establish eligibility or enrollment.
Read the Path Steps
- Welcome video
what the GUIDE program offers, what enrollment involves, and that Lorraine creates an account before she starts.
- Social needs form (PRAPARE)
housing, food, transportation, and other needs that shape the care plan.
- Video
why questions about Harold's health help the care team plan support.
- Health form (PROMIS-10)
a short, standard measure of overall physical and mental health.
- Video
caring for the caregiver, and why the team asks how Lorraine is doing.
- Caregiver impact form (Zarit)
how caregiving is affecting Lorraine's life.
- Video
the last form, and what happens after she finishes.
- GUIDE care partner survey
the program's short caregiver survey, with Lorraine's signature.
- Closing video
what happens next. The GUIDE program team reviews her answers, confirms eligibility, and submits enrollment to Medicare.
Try It Yourself
Experience the GUIDE enrollment Path the way a family would. Open it on your phone or scan the code. You'll create a free account before you start.
This is a demonstration Path. Please don't enter real health information.
Every Workflow Should Save the Health System Time and Money.
Assign a value to the CMS GUIDE Enrollment Path and see the results.
Path Value Estimation
minutes
per year
How many times your team already does this workflow each year.
per hour
65.5staff hours saved per year
$2,291estimated value per year
Change the assumptions above to see your estimate of time and money saved.
CREATE
The care team builds a CMS GUIDE Enrollment Path once.
Social workers turn the enrollment process they walk through with every family into a structured Path and assign it a value of 21 minutes of staff education time saved per patient.
ENGAGE
Caregivers like Lorraine complete it at home.
Each year, 187 caregivers like Lorraine complete GUIDE enrollment at home with the CMS GUIDE Enrollment Path, saving 21 minutes of education time each.
KNOW
Data shows the impact.
That adds up to 3,927 minutes (65.5 hours) of staff time, worth an estimated $2,291 a year at $35.00 an hour.
IMPROVE
Insights improve the next Path.
Engagement, form answers and questions show where the enrollment steps were clear or confusing, so the team can refine them for the next family.
Every Social Work & Navigation Journey Creates an Opportunity to Improve the Next.
Estimates are illustrative and use the assumptions above. They are not measured results.
Lorraine's Care Leads to More Than One Path.
What begins with Harold's referral to the GUIDE program leads to more than one Path. From enrolling in GUIDE to his assessment visit, his care plan, caregiver support, community resources, a difficult night, respite care and check-ins as Harold's needs change, Lorraine needs guidance at every stage. PATHS connects multiple Paths into an experience tailored to her changing needs, and each Path could save the care team time, not only the first. This journey is illustrative.
Lorraine's Experience Becomes Health System Intelligence.
Lorraine's care for her father doesn't stop at one Path. After enrollment, the social work team could provide a Path for each part of the journey: caregiver support, community resources, care planning, and check-ins as Harold's needs change. Each Path Lorraine completes also shows the team what she engaged with, what she understood and what she still had questions about.
Caregiver Support Path
Lorraine finds support for the demands of caring for her father. How caregivers respond helps the team see who may need more help, and sooner.
Community Resources Path
Lorraine explores the services the team selected for Harold's needs. The barriers families report show where social work support is needed.
Changing Needs Check-in Path
Lorraine shares how things are going as Harold's needs change. That helps the team update the care plan as things change.
The more the health system knows about each patient's experience and journey, the better it can make its workflows. What Lorraine and every other caregiver engage with, understand and ask about becomes health system intelligence: the team learns from every patient and refines each Path, so the next patient's experience is better. Clearer Paths mean fewer repeat calls and less time re-teaching the same education, and that saves time and money across the health system.
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Start With One Enrollment. Learn From Every Family.
Improving social work support doesn't require changing every workflow at once. Start with an enrollment journey that matters to your organization, see how families engage, and use what you learn to improve the experience.