St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
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 including 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 organization policies.
JOB DUTIES AND RESPONSIBILITIES:
Home & Functional Assessment
- Conduct comprehensive, standardized in‑home assessments (e.g., gait, balance, transfer ability, ADLs/IADLs, cognition-informed functional capacity).
- Perform environmental/home safety evaluations (lighting, surfaces, railings, entrances, bathrooms, bedrooms, kitchen, medication storage, wandering risks).
- Screen SDOH (e.g., transportation, housing safety, food security) and caregiver burden.
Care Planning & Intervention
- Provide recommendations for fall-prevention strategies (ie. task simplification, routines, cueing, activity structuring consistent with dementia-informed care).
- Provide resources for caregiver education on safe mobility, transfers, energy conservation, and behavioral cues to reduce agitation during mobility tasks.
- Care Coordination
- Collaborate with GUIDE care navigators, nursing, OT/SLP, geriatricians/PCPs, social work, and community partners; contribute to team case conferences.
- Coordinate referrals for PT, OT, SLP, social services, community‑based organizations as appropriate for DME/ adaptive equipment or home modifications for patient safety
Documentation & Compliance
- Document assessments, care plans, interventions, and outcomes in the EHR consistent with CMS GUIDE program specifications, HIPAA, and payer standards.
- Utilize program-required screening tools and quality measures
- Complete timely visit notes, care coordination notes, quality reporting, and any required CMS model attestation elements.
Quality, Outcomes & Performance
- 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.
- Professional Practice
- Maintain clinical competence in dementia-informed rehabilitation, fall prevention, and home safety best practices.
- Adhere to professional and ethical standards; maintain required licensure and continuing education.
Core Competencies
- Dementia‑capable care: Adjusts communication, pacing, and task structure for cognitive impairment; skilled in caregiver coaching.
- Home safety & DME: Expert in identifying environmental risks and recommending practical modifications and equipment.
- Falls prevention & functional rehab: Designs evidence-based programs tailored to comorbidities and cognition.
- Interdisciplinary teamwork: Excellent collaboration and clear, timely communication across care teams.
- Documentation excellence: Accurate, timely, CMS‑compliant notes and outcomes tracking.
- Maintains confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.
- Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
- Demonstrates/models the Network’s PCRAFT values during interactions with all customers.
- Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
- Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices
- Complies with Network and departmental policies regarding attendance and dress code.
- Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.
PHYSICAL AND SENSORY REQUIREMENTS:
Must be able to sit for up to ninety minutes at a time. Be able to tolerate standing for thirty to forty-five minutes consecutively. Must be able to use hands/fingers to manipulate dials on machines. Must have the ability to lift/move patients up to 200 lbs., push/pull patients weighing up to 200 lbs. Must have the ability to occasionally stoop/bend, squat, crouch, kneel and reach above shoulder level. Must be capable of tactile sensation as it relates to feeling muscle spasms, texture, and skin temperature. Must have the ability to hear as it relates to normal conversation. Must be capable of seeing as it relates to general vision, depth perception, and peripheral vision.
EDUCATION:
Doctoral Degree, Master’s or Bachelor’s degree from an accredited Physical Therapy or Occupational Therapy program. Current CPR certification required.
TRAINING AND EXPERIENCE:
Successful completion of required affiliations in accredited program. Visiting home health experience preferred.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
