Dementia Care Management

Dementia Care is a critical, increasingly necessary component of healthcare in Ventura County. As of 2025 an estimated 7.2 million Americans are living with Alzheimer’s dementia, with 14 million projected cases by 2060. Alzheimer’s is the 6th leading cause of death nationally, the 4th in California, but is 3rd in Ventura county. ¹ The Centers for Medicare and Medicaid Services (CMS) have reported that Ventura County is in the top 25% of counties in California with patients who have an Alzheimer’s or dementia diagnosis.¹

Community Memorial provides care to roughly 95,000 patients in our Health Centers each year. Roughly 18,000 of these patients are 65 or older. Of these, 400+ unique patients have a diagnosis of Alzheimer’s or other dementias.

Community Memorial offers the Dementia Care Program and GUIDE Program for dementia care management. Check with our specialist to see if you or a loved one qualifies for either program.
Call 805-948-5836 or 805-948-6223.

Dementia Care Program

Dementia Care Program (DCM) is a care management program tailored for patients diagnosed with Alzheimer's or any other forms of dementia. Based on UCLA Alzheimer’s and Dementia Care (ADC) Program, Community Memorial’s DCM program supports patients and families in navigating the intricate medical, behavioral, and social aspects of dementia. Led by our Advanced Practice Dementia Care Specialist (DCS), we offer comprehensive and collaborative dementia care within our Health Centers.

Our DCM Program Includes

• 90-minute in-person visit with a Dementia Care Specialist (DCS)
• Personalized care plan for each patient and caregiver
• Follow-up care (available via telehealth and in-person), to ensure the plan of care is implemented and adjusted as necessary.
• DCM also collaborates with other Community Memorial programs and community-based organizations to provide additional services

Eligibility Criteria

• Patient must have a diagnosis of Alzheimer’s or any other form of dementia
• Patient must not reside in a nursing home or be enrolled in hospice
• Patient must be receiving ongoing care from a Community Memorial Primary Care Physician or Neurologist

Insurances accepted

• Fee-for-service (FFS) Medicare
• Gold Coast Health Plan

Guiding an Improved Dementia Experience – GUIDE MODEL

The Center for Medicare and Medicaid Services (CMS) introduced the Guiding an Improved Dementia Experience (GUIDE) Model, which is a voluntary nationwide Medicare model that aims to support people with dementia and their unpaid caregivers.

The GUIDE Model provides Medicare coverage for comprehensive, coordinated dementia care. It aims to improve the quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities. It achieves these goals through:

• Medicare payments for comprehensive care coordination
• Care management package, including caregiver education and support
• Respite services provided by partner agencies

Persons living with dementia (PLWD) enrolled in the GUIDE Model who have moderate or severe dementia will also have an in-home visit. They may be eligible for limited in-home or adult day care respite service benefits.

Eligibility Criteria

To be eligible for the CMS GUIDE Model, the patient must meeting the following:

• Has a confirmed diagnosis of Alzheimer’s or other types of dementia
• Has Medicare Part A&B as primary insurance (not under a managed plan)
• Is not enrolled in a Special Needs Plan (SNP) or PACE (Program for All-Inclusive Care for the Elderly)
• Is not enrolled in Medicare hospice benefit
• Is not living in a long-term nursing home
• Lives within the Community Memorial service area

Enrollment Process

1. A comprehensive appointment is scheduled by the GUIDE Model program administrative team
2. The patient/caregiver completes a required pre-visit questionnaire prior to the assessment
3. The comprehensive assessment is conducted with a Dementia Care Specialist (DCS/NP)
4. The DCS/NP sends information from the appointment to Medicare (CMS) to determine benefits
5. The patient and caregiver receive continued coordinated care from the GUIDE Model program

GUIDE Benefits

1. Home Visits
   1. A home visit is required for some patients within the program who meet criteria determined by Medicare. A home visit helps ensure that you and your caregiver get additional support and evaluate if any safety measures are recommended.
   2. During the home visit we assess:

• The home environment
• How you function in your home, including performing your personal care tasks
• Evaluate safety and fall risk
• Other environmental, social and behavioral factors

2. Respite Fund
   1. Through GUIDE, Medicare offers a yearly amount for eligible GUIDE enrollees so caregivers can take a break when needed.
   2. Respite service support comes from local in-home respite providers and adult day centers partnered with CMH’s GUIDE Model Program to provide these services.
   3. Patients enrolled in the GUIDE Model with moderate to high complexity dementia who have a caregiver are eligible for respite services.
   4. You can use respite service funds for in-home care or adult day services.
   5. Funds renew on July 1 yearly throughout the 8-year program. You cannot carry over unused funds to the following year.

To learn more about the Dementia Care Management programs, including eligibility information, please see our FAQ.

Community Memorial Dementia Care Management Providers

Community Memorial has providers who work directly with patient dementia care, diagnosis, and management. See our first point of contact below, or browse our medical providers.

Marie Nelsen, MSN, NP-BC

Gerontological Nurse Practitioner

Marie is the Dementia Care Specialist (DCS) for the Community Memorial Dementia Care Management Program since 2024. She graduated with a Bachelor’s Degree in nursing from San Jose State University in 1995 and completed her Master’s Degree from UCLA in 2005. She is a member of the Gerontological Advanced Practice Nurses Association and is currently studying for her Gerontology Nursing Certification Commission (GNCC). Geriatric is her passion! She takes great pride in helping patients and their families/caregivers navigate the difficult dementia journey.

Languages

English, Spanish with interrupter

Locations

Community Memorial Health Center
120 North Ashwood Avenue, Ventura, CA 93003

Community Memorial Health Center
1202 Maricopa Highway, Suite A, Ojai, CA 93023

Phone Number

805-948-5836 or 805-948-6223

External Referring Providers

If you are a referring provider outside of Community Memorial Health Centers, and your intent is to request a referral to a Neurologist to manage a patient’s dementia care or to request secondary diagnosis confirmation, please reach out to the Community Memorial Healthcare Referrals department for referral to one of our Neurologists.

Resources

1 – Health Matters Ventura County: Alzheimer’s disease or Dementia, Medicare Population, Measure Period 2023: https://www.healthmattersinvc.org/indicators/index/view?indicatorId=2051&localeId=293ADC%20Ventura%20County%20Area