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Job Summary
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.
Primary Responsibilities:
1. Screening/Assessment- The GRACE Social Worker will provide initial and ongoing assessment of an individual’s psychosocial needs. The social worker will obtain relevant health, social, and financial information from the individual and their caregiver if applicable. The GRACE Social Worker’s assessment should 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. The goal of the in-home assessment is to highlight the individual’s strengths, limitations, and internal/external supports and service needs in order to optimize the individual’s functional status and safely maintain the older adult in his/her home.
2. 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. The social worker works with the older adult and caregiver to identify realistic goals while taking into account such factors as a) the appropriate type of intervention and/or level of care, b) the setting conducive to providing such intervention or care, c) the need for caregiver support to allow for the least restrictive level of care, d) transportation options/barriers and e) the steps to obtaining resources that make the achievement of goals possible.
3. 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. The social worker should monitor the effectiveness of the care plan and modify the plan as necessary to achieve the older adult’s health goals.
4. Education/Health Promotion- The GRACE Social Worker will provide education about community resources, entitlement programs, health care benefits and Advance Directives/Living Wills. The GRACE Social Worker will complete advance directives when appropriate. The GRACE Social Worker will refer individuals and their families/caregivers to the appropriate interdisciplinary team member for identified health education needs.
5. 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. When appropriate and feasible, the GRACE Social Worker will educate and encourage the individual and his or her family/caregiver to advocate on his/her own behalf, fostering independence and empowerment.
6. Collaboration- The GRACE Social Worker will work to create an atmosphere in which social workers build professional relationships with peers and colleagues in the GRACE Interdisciplinary Team. The social worker will work collaboratively with other service providers in arranging referrals or assisting in re-assessment processes as needed. The social worker will serve as an educational resource for staff.
7. Supportive Counseling- The GRACE Social Worker will provide the individual and his or her family/caregivers with supportive counseling as needed. With the intent of assisting the individual and the family/caregiver in coping with the psychosocial impact of chronic and disabling illnesses, the onset of catastrophic illness, end-of-life and bereavement issues, the GRACE Social Worker will provide counseling or psychotherapy as able. The social worker will provide ongoing evaluation for the need of more specialized mental health care and will make appropriate referrals community resources. The GRACE Social Worker should establish and maintain effective therapeutic relations while maintaining appropriate professional boundaries with individuals and their families.
8. Crisis Intervention- The GRACE Social Worker will assess and intervene in any medical or psychiatric crises presented by the individual and participate in developing crisis management and safety plans to minimize the event of future crises.
9. Non-Patient Care Responsibilities- The GRACE Social Worker will enter all patient/family contacts in the electronic record using appropriate formats and templates. This information will be entered in a complete, confidential, and professional manner to ensure information on the patient is shared with other health care staff. This information may be reviewed by a supervisor or peer reviewer on a regular basis. The social worker will establish and maintain positive working relationships with employees, volunteers, patients/consumers and other stakeholders within the health care system and outside community agencies. The social worker will attend all appropriate staff meetings (interdisciplinary team meetings, social work staff meetings, other committees as appropriate or as assigned) and perform other duties as required to meet the mission of the program or the health care system in general. The social worker will collaborate in performance improvement processes and comply with performance measures as required by the health care system for their specific population and/or program. The social worker will participate in activities that solicit feedback from patients and work to enhance services as needed. The social worker may elect to function as field instructor to social work trainees.
Qualifications:
- 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.
- 1+ years’ experience with geriatric patient population strongly preferred.
- Clinical licensure (LCSW, LICSW or LMHC) preferred.
Additional Knowledge, Skills and Abilities:
- 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 interventi