Geriatric Social Worker II

Mass General Brigham•Boston, MA

3d•$98,238•Hybrid

About The Position

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. As part of this initiative, the GRACE Social Worker will play a key role in: 1. Conducting in-home geriatric assessments in collaboration with a GRACE Nurse Practitioner. 2. Developing and implementing individualized care plans using GRACE care protocols. 3. Engaging patients and caregivers in psychosocial support, health education, and goals-of-care discussions. 4. Coordinating care with primary care providers and the GRACE interdisciplinary team to optimize outcomes and reduce unnecessary hospital utilization. This role is an essential part of Mass General Brigham’s commitment to improving care delivery for high-risk older adults through proactive, patient-centered management. The GRACE Social Worker will build strong, lasting relationships with patients—offering culturally responsive care, continuity, and education to help manage complex social and health conditions and promote maximum functioning. We are seeking a full-time, 40-hour Social Worker with weekly schedules consisting of 36 hours of clinical, patient-facing time, and 4 hours of administrative time. This will be a hybrid role with the expectation that the Social Worker will conduct home visits in the Boston/Boston Metro West area up to 2 days per week and work remotely for the remainder of the week. Key components of GRACE Team Care include: - 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. As an independent practitioner of social work, the GRACE Social Worker evaluates psychosocial needs and applies social work interventions with a high degree of autonomy, exercising independent judgment and initiative in carrying out social work functions and in applying social work values and ethics to complex situations.

Requirements

Master of Social Work (MSW) from an accredited school of Social Work required.
Driver's License required.
2+ years of clinical experience in a medical setting required.
Demonstrates proficient clinical judgment and application of professional values and ethics.
Demonstrates proficiency to formulate assessment of risks, crisis intervention, psychosocial assessments, treatment plans, and the documentation of both in a timely manner.
Demonstrates sound clinical judgment and innovation in advocating for clients while maintaining professional boundaries.
Demonstrates proficient working knowledge of internal and external resources and refers appropriately.
Provides a range of evidence-based interventions.
Ability to advocate, coordinate, and continuously communicate with treatment plans with patients, family and the interdisciplinary team.
Incorporates social sensitivity.
If appropriate, utilizes supervision and consultation regularly and appropriately.
Actively seeks assistance with complex cases and situations in a timely manner.
Engages in quality improvement projects, uses data to measure progress.
Knowledge, understanding and ability to negotiate and work in a complex organization.
Demonstrate capacity to effectively communicate findings with a broader audience.

Nice To Haves

1+ years’ experience with geriatric patient population strongly preferred.
Clinical licensure (LCSW, LICSW or LMHC) preferred.
Facilitate skill-based groups.

Responsibilities

Provide initial and ongoing assessment of an individual’s psychosocial needs, including obtaining relevant health, social, and financial information from the individual and their caregiver.
Conduct assessments that include a depression screen, cognitive impairment screen, review of financial status and health care benefits, home safety evaluation, review of social supports, and assessment of caregiver burden.
Develop and implement a comprehensive treatment plan of care with the older adult based on the assessment, identifying realistic goals and considering factors such as intervention type, care setting, caregiver support, transportation options/barriers, and steps to obtaining resources.
Develop a care plan with the GRACE Nurse Practitioner and GRACE Interdisciplinary Team, communicate the plan to the patient, caregiver, and primary care provider, and monitor its effectiveness, modifying as necessary.
Provide education about community resources, entitlement programs, health care benefits, and Advance Directives/Living Wills, completing advance directives when appropriate and referring to interdisciplinary team members for identified health education needs.
Advocate for older adults to ensure access to needed care and resources, and educate/encourage individuals and their families/caregivers to advocate on their own behalf.
Build professional relationships with peers and colleagues in the GRACE Interdisciplinary Team, collaborate with other service providers in arranging referrals or assisting in re-assessment processes, and serve as an educational resource for staff.
Provide supportive counseling to the individual and their family/caregivers to assist in coping with the psychosocial impact of chronic and disabling illnesses, catastrophic illness, end-of-life, and bereavement issues, providing counseling or psychotherapy as able.
Provide ongoing evaluation for the need of more specialized mental health care and make appropriate referrals to community resources.
Establish and maintain effective therapeutic relations while maintaining appropriate professional boundaries with individuals and their families.
Assess and intervene in any medical or psychiatric crises presented by the individual and participate in developing crisis management and safety plans.
Enter all patient/family contacts in the electronic record using appropriate formats and templates in a complete, confidential, and professional manner.
Establish and maintain positive working relationships with employees, volunteers, patients/consumers, and other stakeholders.
Attend appropriate staff meetings (interdisciplinary team meetings, social work staff meetings, other committees as appropriate or as assigned).
Perform other duties as required to meet the mission of the program or the health care system.
Collaborate in performance improvement processes and comply with performance measures.
Participate in activities that solicit feedback from patients and work to enhance services.
May elect to function as a field instructor to social work trainees.