Dementia Care Specialist- GUIDE Dementia Program

The GUIDE model focuses on comprehensive, coordinated dementia care and aims to improve quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities. The Dementia Practitioner works with an experienced dementia care team on the CMS GUIDE project. This individual will be responsible for completing comprehensive assessments and implementing a variety of services, including care planning for the beneficiary with dementia and caregivers, community-based and home visit assessments, creating care plans focused on achieving goals, and working with the patient’s provider care team to guide care and transitional care across the care continuum.

The Dementia Practitioner will be the primary point of contact for patients and their caregivers for dementia intervention services. Additionally, activities include providing Alzheimer’s and other dementia disease-related training, data collection, data entry, community/client management, presentations, referral care, screening, monitoring, care coaching, emotional/social support, and data entry record keeping. This individual will be responsible for identifying patients with dementia, caregivers and receiving referrals from multiple clinics throughout the VCU Health system and beyond the health system.

Essential Job Statements Implements the VCUHS GUIDE Program which consists of training/implementing health coaching, health education, dementia care counseling, care ecosystem, REACH Caregiver, and GUIDE screening tools in EMR. Provides dementia patient and caregiver case management. Conducts GUIDE presentations and outreach work to the community. Performs client screening, triage, referral care, and monitoring. Recruitments to VCUHS GUIDE Program. Participates in event planning for the VCUHS GUIDE Program (Community Awareness).

Conducts evaluation and assessment of GUIDE Program. Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and department.

Patient Population Demonstrates the knowledge and skills necessary to provide equitable care appropriate to the age of the patients served on their assigned unit. Demonstrates knowledge and related competencies of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to their age, specific needs and to provide the equitable care needed as described in departmental policies and procedures.

Employment Qualifications Required

Education:

Bachelor’s Degree in a Human Services field or 2-3 years of Community Health Worker care coordination experience.

Preferred Education:

Master’s Degree from an accredited college or university in gerontology, nursing, or social services.

Licensure/Certification

Required:

The individual will complete training to receive a Certified Dementia Practitioner certification and a minimum of 10 hours of dementia care coordination training and certifications. Licensure/Certification Preferred:
Certification in Health Coaching Certification in Health Education Certification in Dementia Care Minimum Qualifications Years and Type of Required Experience Minimum of two (2) years of Gerontological and intervention delivery work or experience in an administrative/coordinator human services role. Experience in Alzheimer’s disease, or Health Coaching, and Electronic Medical Records (EMR).

Other Knowledge, Skills and Abilities Required:

The ability to develop a care plan. Ability to work independently and directly with and serve clients in the community, to create sustaining health…