Geriatric Social Worker

Mass General Brigham•Somerville, MA

2d•$67,538 - $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. 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.

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.
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.
If appropriate, utilizes supervision and consultation regularly and appropriately.
Facilitate skill-based groups.

Responsibilities

Conduct in-home geriatric assessments in collaboration with a GRACE Nurse Practitioner.
Develop and implement individualized care plans using GRACE care protocols.
Engage patients and caregivers in psychosocial support, health education, and goals-of-care discussions.
Coordinate care with primary care providers and the GRACE interdisciplinary team to optimize outcomes and reduce unnecessary hospital utilization.
Provide initial and ongoing assessment of an individual’s psychosocial needs, including obtaining relevant health, social, and financial information.
Conduct 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 appropriate interventions, care settings, caregiver support, transportation options/barriers, and steps to obtaining resources.
Communicate the care 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.
Complete advance directives when appropriate and refer individuals and their families/caregivers to the appropriate interdisciplinary team member for identified health education needs.
Advocate for older adults to ensure access to needed care and resources, and educate/encourage self-advocacy when appropriate.
Build professional relationships with peers and colleagues in the GRACE Interdisciplinary Team, and collaborate with other service providers.
Provide supportive counseling to individuals and their families/caregivers to assist in coping with the psychosocial impact of chronic and disabling illnesses, catastrophic illness, end-of-life, and bereavement issues.
Provide counseling or psychotherapy as able, and provide ongoing evaluation for the need of more specialized mental health care, making appropriate referrals.
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 all appropriate staff meetings and perform other duties as required.
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.