Geriatric Social Worker
Job Location:
Somerville, NJ - USA
Monthly Salary:
Posted on:
Vacancies:
Job Summary
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.
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 Brighams 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:
in-home geriatric assessments in collaboration with a GRACE Nurse Practitioner.
and implementing individualized care plans using GRACE care protocols.
patients and caregivers in psychosocial support health education and goals-of-care discussions.
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 Brighams 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 patientsoffering 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:
The GRACE Social Worker will provide initial and ongoing assessment of an individuals psychosocial needs. The social worker will obtain relevant health social and financial information from the individual and their caregiver if applicable. The GRACE Social Workers 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 individuals strengths limitations and internal/external supports and service needs in order to optimize the individuals functional status and safely maintain the older adult in his/her home.
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.
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 adults health goals.
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.
- 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.
- 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.
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.
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.
-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
Qualifications:
Master of Social Work (MSW) from an accredited school of Social Work required.
Drivers 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 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.
Additional Job Details (if applicable)
Schedule and Work Model
Full time (40 hours) Monday through Friday consisting of 36 hours of clinical patient-facing time and 4 hours of administrative time.
Hybrid: 3-4 days at patient homes and 1-2 virtual days dependent on patient needs. Home visits are conducted in the Boston and Boston Metro West area.
Reimbursement for mileage tolls and parking provided.
On remote workdays employees must use a stable secure and compliant workstation in a quiet environment. Teams Video is required and must be accessed using MGB-provided equipment.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$67537.60 - $98238.40/AnnualGrade
7EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
