New

Regional Social Worker, Geriatric Resources

Mass General Brigham Community Physicians
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jul 18, 2025
The Opportunity Mass General Brigham's Population Health team is committed to enhancing the health care experience for older adults through personalized, home-based care that supports independence, functionality, and quality of life. We develop innovative programs that deliver care where and when it is needed most. This patient-centered model ensures that care is tailored to the unique needs of each individual. By leveraging interdisciplinary collaboration and proactive care management, our value-based care models address the complex needs of older adults. 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 area up to 2 days per week and work remotely for the remainder of the week. Potential Primary Care clinics include: 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. Master's Degree Mental Health & Behavioral Medicine required or Master's Degree Social Work required Class D Passenger Vehicle Driver's License [State License] Preferred Licensed Clinical Social Worker [LCSW - State License] Preferred Licensed Independent Clinical Social Worker [LICSW - State License] Licensed Mental Health Counselor [LMHC - State License] Clinical Experience in a medical setting 2-3 years required Skills for Success - Demonstrates proficient clinical judgment and application of professional values and ethics. Integration of prior clinical experience into current practice. - 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. Regions and Working Model M-F Eastern Business Hours required Hybrid role requires regional coverage for assigned region Region will be determined based on candidate preference and business needs Regions include Boston, and surrounding, North Shore, South Shore, East of Boston and West of Boston Includes in home patient visits for evaluation for care plan, patient home will be within 45 miles of practices within the region Estimated 10 home visits per week, travel includes 4-5 days per week and MGB sites. Formal structured training program for 60-90 days prior to patient home visits Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.