Geriatric Social Worker

Mass General Brigham•Somerville, MA

1d•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. 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.

Nice To Haves

1+ years’ experience with geriatric patient population strongly preferred.
Clinical licensure (LCSW, LICSW or LMHC) preferred.
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 case s and situations in a timely manner.
Engages in quality improvement projects, uses data to measure progress.
Facilitate skill-based groups.
Knowledge, understanding and ability to negotiate and work in a complex organization.
Demonstrate capacity to effectively communicate findings with a broader audience.

Responsibilities

Screening/Assessment: Provide initial and ongoing assessment of an individual’s psychosocial needs, including 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. The goal is to optimize the individual’s functional status and safely maintain the older adult in his/her home.
Treatment Planning/Goal Setting: Develop and implement a comprehensive treatment plan of care with the older adult based on the assessment, identifying realistic goals while considering intervention type, setting, caregiver support, transportation options/barriers, and steps to obtaining resources.
Care Plan Development: Develop a care plan with the GRACE Nurse Practitioner and GRACE Interdisciplinary Team, communicate it to the patient, caregiver, and primary care provider, and monitor its effectiveness, modifying as necessary.
Education/Health Promotion: Provide education about community resources, entitlement programs, health care benefits, and Advance Directives/Living Wills. Complete advance directives when appropriate and refer individuals to the appropriate interdisciplinary team member for identified health education needs.
Advocacy: Advocate for older adults to ensure access to needed care and resources. Educate and encourage individuals and their families/caregivers to advocate on their own behalf.
Collaboration: 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. Serve as an educational resource for staff.
Supportive Counseling: 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 ongoing evaluation for the need of more specialized mental health care and make appropriate referrals.
Crisis Intervention: Assess and intervene in medical or psychiatric crises and participate in developing crisis management and safety plans.
Non-Patient Care Responsibilities: Enter all patient/family contacts in the electronic record in a complete, confidential, and professional manner. Establish and maintain positive working relationships with employees, volunteers, patients/consumers, and outside community agencies. 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.