Coordinated Care Made the Difference for One Family Caregiver: Rebecca’s Story
After Her Mother’s Dementia Diagnosis, a Los Angeles Woman Found Support for Unpaid Family Caregivers Through Her Mom’s Care Team
Published March 24, 2026
At first, the cognitive changes in Rebecca Short’s 81-year-old mother were subtle—small lapses of memory that didn’t seem alarming. But after she got lost driving to a friend’s house, Short took her to a neurologist.
At the appointment, her mother was diagnosed with dementia. Later that day, before meeting friends for lunch, Short recalled discussing with her mother whether to share the news.
“I want to tell them, but what does it mean?” Short recalled her mother saying. “I think we both felt that way. You've seen it on TV and in movies, but now this is happening in our real life. There is a feeling of uncertainty, of course, but fear. And I think we both felt that. What does that mean for her life and our family's life in the future?”
Uncertainty is a common sentiment for families after learning of a dementia diagnosis. Providers are trained to treat symptoms but have not always had the tools or resources to help patients and their family caregivers learn how to live with dementia.
To better support people with dementia and their caregivers, the CMS Innovation Center launched the Guiding an Improved Dementia Experience (GUIDE) Model in 2024. The GUIDE Model aims to improve the quality of life for people living with dementia by helping them remain safe in their homes and communities through stronger care coordination and management. The model also aims to improve caregivers’ quality of life and reduce their strain through respite services, education and other support.
“We kind of struggled to find resources because we weren't sure where to go. We didn't know anybody that had dementia or Alzheimer's in our family,” Short said.
Short found what she was looking for when she contacted the University of California, Los Angeles Alzheimer's and Dementia Care Program, a participant in the CMS GUIDE Model.
“At that time, Rebecca, her dad and her mom, were having a rough time because mom had a pretty significant decline,” said Michelle Panlilio, a nurse practitioner and National Lead Dementia Care Specialist at UCLA. "Rebecca did a lot to help her parents navigate through their health care.”
The program at UCLA helped Short and her father manage caring for her mother with an entire care team dedicated to helping the family. The GUIDE care team helped them make informed decisions to best meet the medical, social and behavioral needs of their loved one. The team included Panlilio, whom Short could contact with questions in real time, and a counselor to talk to about her caregiving challenges and fears. Short also had the option to take her mother to adult day care, providing her with much-needed respite.
“All of a sudden, we felt there's hope,” Short said. “There are resources… there's people that can guide us through the stages and help us understand.”
For a while following her diagnosis, Short said her mother continued several activities she enjoyed, including regular walks through her Los Angeles neighborhood where she grew up and reading the morning newspaper at the breakfast table. Short said her mother had instilled a love of reading in her at a young age, and later, when Short was an adult, the two had been in a book club together. Though her mother’s health eventually deteriorated, Short remained comforted that her mother continued to recognize her before she passed away in 2025.
What advice does Short have for other families navigating a dementia diagnosis? “Don't be afraid to call and ask for help,” she said.