Geriatric Social Worker II

Mass General Brigham Social Worker Position

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

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:

• Conducting in-home geriatric assessments in collaboration with a GRACE Nurse Practitioner.
• Developing and implementing individualized care plans using GRACE care protocols.
• Engaging patients and caregivers in psychosocial support, health education, and goals-of-care discussions.
• 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.

Primary Responsibilities:

• Screening/Assessment:
  The GRACE Social Worker will provide initial and ongoing assessment of an individual's psychosocial needs.
• Treatment Planning/Goal Setting:
  It is the responsibility of the GRACE Social Worker, working with the GRACE Interdisciplinary Team, to develop and implement a comprehensive treatment plan of care with the older adult based on the assessment.
• Care Plan Development:
  The GRACE Social Worker should work with the GRACE Nurse Practitioner and GRACE Interdisciplinary Team to develop a care plan and communicate that plan to the patient, caregiver, and the primary care provider.
• Education/Health Promotion:
  The GRACE Social Worker will provide education about community resources, entitlement programs, health care benefits and Advance Directives/Living Wills.
• Advocacy:
  The GRACE Social Worker will advocate for older adults to ensure that they have access to all needed care and resources within the community.
• Collaboration:
  
  The GRACE Social Worker will work to create an atmosphere in which social workers build…