Memory Care Social Worker at Tufts Medical Center

Job Profile Summary
This new position is central to the Tufts Medicine Memory Care Program, supporting individuals living with dementia and their caregivers through comprehensive social work services. The Memory Care social worker will play a key role in supporting the Guiding an Improved Dementia Experience (GUIDE) Model, an innovative payment model developed by the Center for Medicare and Medicaid Innovation. Additionally, the social worker will provide essential support to families of patients treated within the interdisciplinary memory care clinic and primary care, ensuring continuity of care and promoting early detection through memory screenings. This role is integral to the program’s goal of establishing a comprehensive, interdisciplinary Memory Care Program, which will integrate medical and non-medical services to improve patient outcomes, retention, and overall quality of life for both individuals with neurocognitive disorders and their caregivers.

Job Overview
The Memory Care social worker will provide clinical services, support, education, and resource coordination to patients and caregivers, with a focus on integrating services within both primary care and specialty care in the interdisciplinary memory clinic. The social worker will be a key contributor, providing clinical services and helping to triage patients into appropriate levels of care. Additionally, the role will involve close collaboration with the interdisciplinary team to ensure unified integration of services and support, which is crucial to both disease management and program differentiation.

Minimum Qualifications:

Master’s degree in Social Work from an accredited institution.

Licensed Clinical Social Worker (LCSW) or ability to become licensed in Massachusetts.

At least one (1) year of experience in a health care setting, with an emphasis on dementia care.

Preferred Qualifications:

Three (3) years of related experience, particularly in dementia care or working with older adults.

Experience in interdisciplinary care coordination, crisis intervention, and caregiver support.

Duties and Responsibilities:

GUIDE Model and Primary Care Support: Provide social work services as part of the interdisciplinary care team for the GUIDE Model, ensuring compliance with CMS requirements and delivering tailored support to patients within primary care settings.

Patient Screening: Participate in the memory screening process, promoting early detection and prevention of dementia. Help triage patients into specific levels of care based on risk stratification, ensuring timely and appropriate interventions.

Memory Clinic and Specialty Care Support: Offer clinical services, support, and care coordination for families of patients treated in the interdisciplinary memory clinic, facilitating seamless transitions between primary and specialty care. Caregiver Support and Education: Deliver strategies and resources to help caregivers manage the challenges of dementia care, improving their quality of life and reducing caregiver burnout. Provide education on disease progression, care strategies, and available support services, which is essential for patient retention and overall program success.

Care Plan Development: Collaborate with healthcare teams to develop personalized care plans for individuals with dementia, integrating both medical and psychosocial support tailored to each patient's unique needs.

Crisis Intervention and Resource Coordination: Provide crisis intervention services and connect families to appropriate community resources, including home care services, respite care, and dementia-specific support groups. Interdisciplinary Collaboration: Work closely with other members of the interdisciplinary care team, including Care Navigators, physicians, and other dementia care specialists, to ensure comprehensive care coordination and support for GUIDE participants and memory clinic patients.

Patient Advocacy: Act as an advocate for patients and their families, ensuring dignity, respect, and access to all available services and resources throughout their care journey.

Program Differentiation: Support the integration of non-medical services into the memory care program, particularly caregiver support and education services, which are critical to both the effectiveness of disease management and the program’s differentiation in the field of dementia care.

Skills & Abilities:

Strong understanding of dementia care, neurocognitive disorders, and the associated challenges facing patients and caregivers. Excellent interpersonal and communication skills, with the ability to build trust and rapport with patients, families, and the healthcare team. Knowledge of community resources, dementia-related support services, and the case management process. Ability to function effectively in high-stress situations, such as crisis interventions and family consultations. Commitment to continuous learning in dementia care advancements, including therapeutic innovations and research.

Physical Requirements:

Normal office setting and patient care environments.

This role is integral to the success of the Tufts Medicine Memory Care Program, positioning the organization as a leader in dementia care. The social worker will support the program’s mission to enhance quality of life for individuals living with dementia, reduce caregiver strain, and promote patient retention through comprehensive, interdisciplinary care services.