Per Diem GUIDE Home Assessment Therapist

CO30 St Lukes Physician Group Inc; Center Valley (Lehigh County); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Luke's University Health Network seeks a GUIDE Home Assessment Therapist to perform comprehensive, in-home assessments for older adults with dementia under the CMS GUIDE model.

You will evaluate mobility, home safety, caregiver capacity, and social determinants of health, and collaborate with an interdisciplinary team to reduce fall risk and support aging‑in‑place. Documentation, care planning, and community referrals are key components of the role.

Qualifications

• Doctoral, Master's or Bachelor’s degree in Physical Therapy or Occupational Therapy.
• Current CPR certification is required.
• Home health experience preferred.

Responsibilities

• Conduct comprehensive in-home assessments (mobility, balance, ADLs/IADLs, cognition-informed capacity).
• Develop care plans and Fall-prevention interventions tailored to dementia-informed care.
• Coordinate referrals for PT/OT/SLP and related services with the care team.
• Document assessments and outcomes per CMS GUIDE and HIPAA standards.
• Support continuous quality improvement and staff training in dementia-capable care.
• Adhere to professional standards and maintain licensure and continuing education.

Skills

Home assessments

Care planning

Interdisciplinary collaboration

Documentation

Education

PT/OT degree

Tools

EHR systems

CMS GUIDE

Job description

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.

Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer. Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non‑profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley‑based health care system to earn Medicare’s five‑star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row.

Learn More Here.