The Blueprint for Scale
How AgeSpan Built a Statewide Dementia Care Blueprint and Unlocked Sustainable Revenue through the GUIDE Model
The Vision & Localized Opportunity
Operating in a highly dense, strictly regulated Northeast landscape, AgeSpan recognized CMMI’s GUIDE program as a historic, sustainable mechanism to expand their community footprint and unlock critical, non-grant recurring revenue. This opportunity was underscored by a Massachusetts community needs assessment revealing that a staggering 71% of local caregivers desperately needed respite care - a critical gap that the GUIDE model was specifically engineered to bridge. To turn this blueprint into immediate reality, AgeSpan rapidly mobilized their regional grid, spreading the word in close collaboration with an expansive network of trusted community partners to optimize client intake from day one.
GUIDE Program Success Story: Restoring Balance at Home
Beneficiary PD, an 89-year-old male, was successfully aligned with the GUIDE program within a week of his initial referral. The care navigator immediately put a baseline of support in place, setting up Meals on Wheels to ease daily prep before conducting a home assessment to launch tailored respite services. PD, a passionate former hairdresser of 65 years, bonded so beautifully with his new aide that his wife sent a photo of him happily cutting the aide's hair. These weekly companion visits give the caregiver a vital, much-needed break to run errands, while monthly navigator check-ins provide her with ongoing clinical education and support. This GUIDE program is phenomenal!
Building the Blueprint
Internal Asset Auditing & Referral Network Mapping: Before looking outward, AgeSpan mobilized their Case Managers to systematically audit active client lists and relative agency programs to pinpoint immediately eligible individuals. By blending this internal roster optimization with external clinical pathways—connecting directly with regional hospital systems and primary care clinics—the HUB engineered a high-velocity, dual-source pipeline from day one.
Workforce Readiness: CCS Health + Healthspan immediately trained AgeSpan's crew to ensured Care Navigators were fully certified and dementia-proficient before the program went live.
Software Infrastructure: We deployed the Community Health Record (CHR) platform. This took the heavy technical lift of claims, CMS invoicing, and provider credentialing off AgeSpan’s shoulders from day one, empowering Care Navigators and Administrative teams to handle the clinical/social care connection while the platform handles the back-end logistics.
Building the HUB
AgeSpan transformed its complex regional footprint into a high-performance community matrix, leveraging the CCS platform to instantly vet, onboard, and coordinate an extensive horizontal web of collaborating AAAs, ASAPs, and independent respite networks. This expansive infrastructure allowed the HUB to standardize complex social-care workflows and deliver seamless geographic coverage across a mixed network of in-home, adult day, and 24/7 facility respite options without putting structural strain on their internal team.
From Blueprint to Footprint
The Expanding Horizon:
Having established a master-planned regional network grid and optimized high-velocity client intake in Year 1, AgeSpan is shifting from localized community alignment to true institutional scale. The next era of the program embeds the GUIDE model directly into the Northeast’s premier clinical infrastructure by launching a landmark integration with Tufts Medicine Interated Network, capturing high-volume, automated referral streams across the dense metropolitan landscape.
Special thanks to our AgeSpan GUIDE Champion
Mary DeRoo, RN, BSN, MSM
Leads healthcare integration and new business development for AgeSpan, based in Lawrence, Massachusetts. She brings extensive experience across the aging services network, with a professional background that spans both clinical practice and executive leadership.
Prior to her current role, Mary served as Home Care Director at AGE (formerly the Massachusetts Executive Office of Elder Affairs), where she played a pivotal role in advancing statewide home care initiatives. She worked with multiple insurers in quality, compliance and community transitions of care as the Director of the Physician Hospital Organization for Tufts Medicine Integrated Network. She served as Regional Nurse Director for the personal care line at Amedysis overseeing the clinical operations and care delivery across multiple locations in Massachusetts, as well as Florida and Tennessee.
Most recently, Mary has been instrumental in bringing the GUIDE (Guiding an Improved Dementia Experience) Program to AgeSpan. She also established a regional care collaborative that includes 18 other ASAP/AAA organizations across the hub. Through this work, she has expanded access to respite services by coordinating with more than 40 providers, ensuring caregivers receive the critical support and relief needed to sustain their caregiving roles.
For 15 years, CCS Health has helped communities turn vision into action. As a social good company, we partner with organizations nationwide to strengthen community health through workforce development, purpose-built technology, and community-centered solutions.
From Community Care HUBs to Area Agencies on Aging - from twinkle to wrinkle - we believe local organizations are the foundation for healthier communities. Together, we're helping AAAs and Tribes serve as national leaders in sustainable health transformation through GUIDE, Care Transitions Intervention®, Rural Health Transformation, and Community Care HUBs. Bringing Care to People. People to Care. Together, we're building the future of community health.
Join us as a Partner in Sustainable Community Health
Healthspan Partners is a multi-state geriatrics practice that partners with Area Agencies on Aging and other community-based organizations to deliver the CMS GUIDE Model. Our mission is to help AAAs build a self-sustaining dementia care service to reach and support more families living with dementia while strengthening the home- and community-based care network in their communities.