GUIDE Home Assessment Therapist

St. Luke’s University Health Network•Center Valley, PA

About The Position

The GUIDE Home Assessment Therapist performs comprehensive in-home assessments and interventions for older adults living with dementia and related conditions under the CMS GUIDE (Guiding an Improved Dementia Experience) model. The therapist evaluates mobility, balance, functional performance, home safety, caregiver capacity, and social determinants of health (SDOH); recommends individualized plans that may include exercise, environmental modifications, and durable medical equipment (DME); and collaborates with an interdisciplinary team to reduce fall risk, support aging in place, and enhance caregiver well-being. The therapist documents services in accordance with CMS GUIDE model requirements and organizational policies. The role includes conducting standardized functional and home-safety assessments; developing fall-prevention and caregiver-education recommendations; coordinating referrals and care with clinical and community partners; and maintaining accurate, timely documentation and quality reporting. The therapist also participates in continuous quality improvement, program evaluation, data collection, and staff training related to dementia-capable care. The position requires maintaining clinical competence and professional standards, confidentiality, compliance with organizational policies, and appropriate assessment, treatment, and communication based on patients’ ages and needs. The role also includes demonstrating the Network’s PCRAFT values, supporting performance improvement, and using resources responsibly.

Requirements

Doctoral, master’s, or bachelor’s degree from an accredited Physical Therapy or Occupational Therapy program.
Current CPR certification.
Successful completion of required affiliations in an accredited program.
Maintain required licensure and continuing education.
Ability to sit for up to 90 minutes at a time and stand for 30 to 45 minutes consecutively.
Ability to manipulate machine dials using hands and fingers.
Ability to lift and move patients up to 200 pounds and push or pull patients weighing up to 200 pounds.
Ability to occasionally stoop or bend, squat, crouch, kneel, and reach above shoulder level.
Tactile sensation sufficient to feel muscle spasms, texture, and skin temperature.
Hearing sufficient for normal conversation.
Vision sufficient for general vision, depth perception, and peripheral vision.
Demonstrated competence in dementia-capable care, caregiver coaching, home safety and DME recommendations, fall prevention, functional rehabilitation, interdisciplinary teamwork, and accurate documentation.

Nice To Haves

Visiting home health experience.

Responsibilities

Conduct comprehensive, standardized in-home assessments of gait, balance, transfers, activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and cognition-informed functional capacity.
Evaluate home safety, including lighting, surfaces, railings, entrances, bathrooms, bedrooms, kitchens, medication storage, and wandering risks.
Screen for social determinants of health, such as transportation, housing safety, and food security, and assess caregiver burden.
Recommend individualized fall-prevention strategies, including task simplification, routines, cueing, and activity structuring consistent with dementia-informed care.
Provide caregivers with resources and education on safe mobility, transfers, energy conservation, and behavioral cues to reduce agitation during mobility tasks.
Collaborate with GUIDE care navigators, nursing, occupational therapy, speech-language pathology, geriatricians or primary care providers, social work, and community partners; contribute to team case conferences.
Coordinate referrals for physical therapy, occupational therapy, speech-language pathology, social services, community-based organizations, durable medical or adaptive equipment, and home modifications as appropriate.
Document assessments, care plans, interventions, and outcomes in the EHR in accordance with CMS GUIDE specifications, HIPAA, payer standards, and organizational policies.
Use program-required screening tools and quality measures; complete timely visit notes, care coordination notes, quality reporting, and required CMS model attestation elements.
Participate in continuous quality improvement, program evaluation, and staff training for dementia-capable care.
Support data collection for CMS reporting and organizational value-based care goals.
Maintain clinical competence in dementia-informed rehabilitation, fall prevention, and home-safety best practices; maintain required licensure and continuing education.
Maintain confidentiality and comply with information-release, safety, attendance, dress-code, and other Network and departmental policies.
Demonstrate the Network’s PCRAFT values, performance improvement, financial responsibility, and effective use of resources.
Demonstrate assessment, treatment, growth-and-development knowledge, and communication appropriate to the age of the patient treated.