How Pocketrn Is Leveraging Home Care To Navigate Cms’ Guide Model

Since the launch of the Centers for Medicare & Medicaid Services’ (CMS) Guiding an Improved Dementia Experience (GUIDE) Model last year, virtual nursing platform PocketRN has formed an abundance of strategic home care-focused partnerships with the goal of supporting seniors living with dementia.

For those who’ve been watching PocketRN closely, its strong ties to the home-based care industry should come as no surprise.

“Home care has been our focus from day one at PocketRN,” CEO Jenna Morgenstern-Gaines, told Home Health Care News. “Our team is made up of home care veterans, and as a family caregiver myself, I’ve seen firsthand the power of the combination of home care and having a nurse for life, who is a dedicated, specialized nurse that builds a trusted relationship with you, and becomes a part of the family. We built PocketRN to integrate with home care.”

Palo Alto, California-based PocketRN partners with home care and home health providers to offer patients personalized, virtual nursing services. The company also works with hospitals, health systems, payers and offers remote patient monitoring.

The company’s Nurse For Life model matches older adults with a specialized nurse that helps them navigate the complexities of care in the home, Morgenstern-Gaines previously told HHCN.

As part of its GUIDE efforts, PocketRN has partnered with Synergy HomeCare, Cornerstone Caregiving, Homewatch CareGivers, Assisting Hands Home Care, Right at Home, Comfort Keepers, HomeWell Care Services, Caring Senior Service, A Place at Home and Interim HealthCare.

Morgenstern-Gaines noted that PocketRN also has numerous partnerships that have yet to be announced publicly, including ones with tech companies and other organizations that help the company offer seniors and their families access to additional resources.

“In addition to home care, PocketRN’s approach to the GUIDE model gives families access to a broader ecosystem — from medically tailored meals to games and tools that help families connect with each other — giving them more quality time together,” she said. “These partners complement clinical care and the Nurse for Life model, helping ensure families have the right kind of support for the bad days, and more ways, and more energy, to enjoy the good days.”

When identifying potential home care partners, PocketRN looks for a few things: mission alignment, commitment to quality of care and an appetite for innovation.

“The best home care partners under GUIDE have become true heroes in their communities,” Morgenstern-Gaines said. “They’ve positioned themselves as vital resources for families living with dementia, and for community partners who support them, by providing education and a clear pathway to engage in the GUIDE program.”

PocketRN says its partners are its eyes and ears in the home. This is crucial because it allows the company to catch health issues early and prevent unnecessary visits to the emergency room.

As a company in the virtual care space, having caregivers and clinicians in the home also gives the PocketRN “a human touch,” which is critical when working with seniors living with dementia, according to Morgenstern-Gaines.

“It makes them feel supported and makes it a long-term trusted relationship, not a transactional relationship,” she said. “The secret sauce really comes from that combination of in-home caregiving with that virtual nursing care wrap-around, that’s what helps keep people healthy at home for longer.”

As a result, PocketRN has seen an over 30% reduction in emergency department visits and re-admissions in its patient population.

“That is a huge cost savings to the system, and so much better for the patients, and their families, not to be disrupted by a visit to the ED or to the hospital,” Morgenstern-Gaines said.

The company also reports achieving a 98% satisfaction rating among patients, clients, and their families.

Ultimately, PocketRN’s participation in GUIDE has underscored the importance of flexibility and adaptability as a company, according to Morgenstern-Gaines.

“Dementia itself is complex, and every journey looks different, which is why we built an ecosystem that tries to balance national reach with personalized care,” she said.

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