GUIDE Assessment Therapist

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.

• 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.
• 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.
• 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.
• 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.
• 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; adhere to professional and ethical standards; maintain required licensure and continuing education.

• 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…