Why Caregiver Education Is a Strategic Advantage in the CMS Medicare ACCESS Model
The CMS Innovation Center’s newly announced ACCESS (Accelerating Clinical Evidence, Systems, and Solutions) Model signals that Medicare continues to double down in chronic condition care. Measurable outcomes will lead reimbursement decisions, meaning treating the root cause of these conditions will become even more impactful. This model challenges ACCESS participants, providers, health systems, and traditional Medicare, Medicare Advantage, and even Medicaid plans to rethink how care is delivered and how success becomes sustainable for ACCESS organizations.
Achieving better health outcomes requires more than clinical excellence alone. What happens between primary care visits, outside the clinic, and in the home are also heavily weighted in this new equation. How can you be sure to set the stage for success? It’s simple—empower family caregivers.
What Is the CMS ACCESS Model?
ACCESS is a voluntary, outcomes-based payment model designed to improve chronic disease management among Medicare Fee-for-Service beneficiaries. Participating organizations and providers receive prospective payments tied to their ability to help patients achieve defined clinical and functional outcomes, such as improved blood pressure control, better symptom management, or increased functional ability.
Unlike traditional fee-for-service programs, the CMS ACCESS model offers significant flexibility in care design. CMS intentionally allows organizations to use technology-enabled approaches, care coordination strategies, and non-traditional supports to help patients meet outcome targets. Participants may include providers, health systems, ACOs, Medicare plans, and non-provider partners that can support scalable, patient-centered care.
The intent of this model is to inspire innovation. Organizations can get creative as they look for new levers to pull to improve the health of the Medicare populations they serve. At Trualta, we know that you don’t have to search too far to find an ACCESS game changer—look to family caregivers.
CMS Must Acknowledge That Chronic Care Management Starts at Home
Even though CMS doesn’t name caregivers in the ACCESS documentation, the model’s core expectations (outcomes, engagement, continuous support, coordinated care) places strong emphasis on elements deeply influenced by caregiver involvement:
- Patient engagement and adherence
- Ongoing support between clinical encounters
- Technology-enabled, home-based care
- Longitudinal management of chronic conditions
- Measurable improvement over time
In other words, the success factors CMS prioritizes are difficult to achieve without family caregivers.. Chronic conditions are managed daily through medication routines, dietary choices, physical activity, safety practices, and symptom monitoring.
Family caregivers are often the captains of the ship, yet most receive little to no formal training. They are expected to support complex care needs of the Medicare beneficiary without structured education or guidance. Often, the only instruction they receive is upon patient discharge. In 2025, it was estimated by the National Alliance of Caregiving that 22% of caregivers are of Medicare age, and nearly a third of those are 75+. These are Medicare members caring for each other.
How do we help caregivers stick to care plans, recognize warning signs, or help guide their care recipients to make better daily choices? All of which directly affect the outcomes ACCESS is designed to measure.
Where Trualta Fits in the ACCESS Ecosystem
Trualta supports organizations participating in CMS ACCESS model by addressing this critical enablement gap: caregiver support and family education.
Delivering evidence-informed, condition-specific education through technology supported care that helps caregivers and families better understand chronic conditions, manage daily tasks, and support long-term behavior change. Trualta’s platform integrates easily with existing tech and care coordination workflows, extending the care team into the home. Trualta serves as a source of encouragement and support, offering practical tools and resources tailored to the unique needs of caregivers.
Where in Medicaid services or the Medicare eco-system do care managers, case managers, discharge nurses, etc. have the bandwidth to educate family caregivers upon a new diagnosis, or provide counsel about the nuances and red flags to look for in these chronic conditions? By partnering with Trualta, caregivers have on-demand access to thousands of hours of content including:
- 172 unique modules related to anxiety and mental illness
- 226 content modules focusing on diabetes and kidney disease
- 98 modules related to heart health
- 208 unique educational modules about caring for someone who has suffered a stroke
And this is just a sampling of the resources available to guide and build confidence in the at-home care they are able to provide.
Sue’s Caregiving Experience with Trualta.
Caregiver Education is a Force Multiplier for Medicare
Caregiver education is a Medicare plan improvement strategy that directly influences health outcomes. When caregivers understand conditions, risks, and chronic disease care plans, they are better equipped to support patients consistently over time.
Plans have the ability to level-up the ACCESS model by including Trualta in their partner ecosystem.
How can Trualta enable Medicare plans to care for their beneficiaries?
- Improve member engagement, satisfaction, and adherence
- Educate caregivers resulting in fewer preventable complications and over-utilization
- Reduce downstream costs associated with unmanaged chronic conditions
- Standardize caregiver support across diverse provider networks
- Demonstrate alignment with CMS Innovation Center priorities
By offering caregiver education as a network-level resource, plans can strengthen performance while advancing chronic care and value based care goals. Plans who see the most success incorporate Trualta into their Provider Relations, Care Management workflows, and transitions of care.
Learn more about de-risking care transitions with the help of family caregivers here.
ACCESS rewards sustained improvement, not episodic intervention, making daily behaviors central to financial and clinical success.
Preparing for ACCESS In 2026
ACCESS participation timelines are approaching quickly, and organizations that invest early in enablement infrastructure will be better positioned to succeed. Caregiver engagement is one of the most scalable, low-friction ways to support patient outcomes without increasing clinical burden.
As CMS continues to expand value-based models, organizations that integrate caregiver education and support into their care strategies will be better equipped to translate flexibility into measurable results.
Trualta is proud to partner with provider networks and Medicare plans to transform ACCESS from a policy framework into a practical, sustainable pathway to better outcomes.
References:
- Centers for Medicare & Medicaid Services. Access Model Overview FAQ
- National Alliance for Caregiving; (2025). Report: Transforming Family Caregiving Through Data.
