Geriatric Social Worker

Job Summary This is an exciting opportunity to join the Mass General Brigham Population Health department as a Social Worker within the GRACE (Geriatric Resources for Assessment and Care of Elders) program. The GRACE Social Worker will provide home-based geriatric assessment and care management for older adults aligned with Mass General Brigham’s Primary Care Providers. This role is designed to proactively support vulnerable older adults, ensuring comprehensive, coordinated care that aligns with their goals and preferences. Key Components of GRACE Team Care In-home assessments by a nurse practitioner and social worker team. Individualized care plans developed using GRACE protocols. Collaborative care planning with primary care physicians. Ongoing home‑based care management and coordination. Weekly interdisciplinary team meetings including a geriatrician, pharmacist, and mental health liaison. Primary Responsibilities Screening/Assessment – Provide initial and ongoing assessment of psychosocial needs, obtaining health, social, and financial information, depression screen, cognitive impairment screen, review of financial status and health care benefits, home safety evaluation, social supports, and caregiver burden assessment. Treatment Planning/Goal Setting – Work with the interdisciplinary team to develop and implement a comprehensive treatment plan, identify realistic goals, and consider intervention type, setting, caregiver support, transportation, and resource acquisition. Care Plan Development – Collaborate with the nurse practitioner and interdisciplinary team to develop a care plan, communicate with patient, caregiver, and primary care provider, monitor effectiveness, and modify as needed. Education/Health Promotion – Provide education on community resources, entitlement programs, health care benefits, Advance Directives, and Living Wills; complete advance directives when appropriate; refer to interdisciplinary team members for health education needs. Advocacy – Advocate for older adults to ensure access to needed care and resources; encourage independence and empowerment. Collaboration – Build professional relationships with peers; arrange referrals or re‑assessment processes; serve as an educational resource for staff. Supportive Counseling – Provide supportive counseling to individuals and families; assess need for specialized mental health care and make appropriate referrals. Crisis Intervention – Assess and intervene in medical or psychiatric crises; develop crisis management and safety plans. Non‑Patient Care Responsibilities – Enter patient/family contacts in electronic record; maintain confidentiality; attend interdisciplinary team meetings and other committees; participate in performance improvement processes; provide feedback to enhance services; may act as field instructor to trainees. Qualifications Must hold a Master of Social Work (MSW) from an accredited school of Social Work. Valid driver’s license. Minimum 2 years of clinical experience in a medical setting. At least 1 year’s experience with a geriatric patient population strongly preferred. Clinical licensure (LCSW, LICSW, or LMHC) preferred. Additional Knowledge, Skills, and Abilities Demonstrated clinical judgment and application of professional values and ethics. Proficiency in risk assessment, crisis intervention, psychosocial assessment, treatment planning, and timely documentation. Advocacy for clients while maintaining professional boundaries. Knowledge of internal and external resources and appropriate referrals. Ability to provide evidence‑based interventions. Effective communication of treatment plans with patients, families, and interdisciplinary team. Social sensitivity and cultural competence. Regular use of supervision and consultation as needed. Timely assistance with complex cases and situations. Engagement in quality improvement projects and data use. Facilitation of skill‑based groups. Understanding of navigating complex organizations. Communication of findings to broader audiences. Schedule and Work Model Full‑time (40 hours) Monday through Friday: 36 hours of clinical, patient‑facing time and 4 hours of administrative time. Hybrid: 3-4 days at patient homes and 1-2 virtual days as needed; home visits conducted in Boston and Boston Metro West area. Reimbursement for mileage, tolls, and parking provided. Remote days require a stable, secure, compliant workstation in a quiet environment; Teams Video access required with company equipment. Pay Range $67,537.60 – $98,238.40 per year. Location 399 Revolution Drive. EEO Statement 6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and other protected statuses. Reasonable accommodations will be provided for individuals with disabilities. For accommodations, contact Human Resources at View phone number on click.appcast.io. #J-18808-Ljbffr Mass General Brigham