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 to meet CMS GUIDE model requirements and organizational policies. The role includes home and functional assessment, care planning and intervention, care coordination, documentation and compliance, quality and outcomes activities, and professional practice. The therapist supports caregiver education, coordinates referrals and resources, contributes to team case conferences, participates in continuous quality improvement and staff training, and supports CMS reporting and value-based care goals. The therapist also follows confidentiality, safety, attendance, dress-code, ethical, and organizational requirements, and demonstrates appropriate age-related assessment, treatment, and communication competency.

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 use hands and fingers to manipulate machine dials.
Ability to lift or 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 for normal conversation; and vision including depth and peripheral perception.

Nice To Haves

Visiting home health experience preferred.

Responsibilities

Conduct comprehensive, standardized in-home assessments of gait, balance, transfers, activities of daily living (ADLs), 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, including transportation, housing safety, and food security, and assess caregiver burden.
Recommend fall-prevention strategies such as task simplification, routines, cueing, and activity structuring consistent with dementia-informed care.
Provide caregiver education resources on safe mobility, transfers, energy conservation, and behavioral cues that may reduce agitation during mobility tasks.
Collaborate with GUIDE care navigators, nursing, OT/SLP, geriatricians and primary care providers, social work, and community partners; contribute to team case conferences.
Coordinate referrals for PT, OT, SLP, social services, community-based organizations, DME or adaptive equipment, and home modifications as appropriate for patient safety.
Document assessments, care plans, interventions, and outcomes in the EHR in accordance with CMS GUIDE specifications, HIPAA, and payer standards.
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 practices; maintain required licensure and continuing education.
Maintain confidentiality and comply with information-release requirements, organizational policies, safety and reporting requirements, attendance and dress code, and professional and ethical standards.
Demonstrate the Network’s PCRAFT values, performance improvement, financial responsibility, efficient use of resources, and age-appropriate assessment, treatment, and communication competency.