Geriatrician

About this role

Scheduled Weekly Hours: 40 - The Geriatrician provides comprehensive, patient-centered medical care to older adults across two primary settings: (1) outpatient clinic and (2) community-based environments. This role is intentionally split 50% in-clinic (evaluation, longitudinal management, consultations) and 50% in the community (home-based primary care, assisted living/SNF visits, transitional care, and outreach). The clinician will emphasize function, quality of life, medication safety, goals-of-care alignment, and coordination across the care continuum. Work Schedule & Location • Schedule: Full-time split 50% clinic / 50% community • Clinic Location(s): Attleboro, MA • Community Coverage Area: Bristol & Norfolk Counties • Travel: Required for community visits; valid driver’s license and reliable transportation • On-call: None / Shared rotation / After-hours phone triage

Key Responsibilities A. Outpatient Clinic (50%) Comprehensive Geriatric Assessment • Conduct multidimensional evaluations including medical complexity, functional status, cognition, mood, fall risk, nutrition, sensory impairment, caregiver support, and social determinants of health.

Chronic Disease Management • Provide evidence-informed management of common geriatric conditions (e.g., frailty, dementia, delirium risk, polypharmacy, osteoporosis, urinary incontinence, heart failure, COPD, diabetes in older adults).

Medication Optimization • Perform structured medication reviews, deprescribing when appropriate, and reconciliation after transitions of care.

Cognitive and Behavioral Health Care • Diagnosing and managing dementia, mild cognitive impairment, delirium risk, depression, anxiety, and behavioral symptoms in partnership with caregivers and community support.

Preventive Care & Risk Reduction • Tailor screening and preventive strategies to life expectancy, function, patient values, and clinical context; address falls prevention and mobility preservation.

Care Planning & Advance Care Planning • Facilitate goals-of-care discussions; document advanced directives/POLST/MOLST where applicable; align treatment plans with patient preferences.

Consultation & Co-Management • Provide geriatric consults for complex older adults and collaborate with PCPs and specialists.

B. Community-Based Care (50%) Home-Based and Community Geriatrics • Deliver medical care in patient homes and community settings (e.g., assisted living, adult day programs, supportive housing) for patients with mobility, cognitive, or access barriers.

Post-Acute & Facility-Based Rounding (as applicable) • Provide continuity visits in skilled nursing facilities (SNFs) or other residential settings, coordinate with facility staff on care plans and safety.

Transitional Care Management • Support hospital-to-home (or SNF-to-home) transitions, including timely follow-up, medication reconciliation, symptom monitoring, and coordination with home health and caregivers.

Urgent Access & Acute Issue Management (in scope) • Evaluate and manage subacute changes (e.g., delirium triggers, falls, dehydration, infection risk) while reducing avoidable ED visits/hospitalizations when clinically appropriate.

Interdisciplinary Team Collaboration • Partner with nursing, social work, care management, pharmacy, PT/OT, behavioral health, and community agencies to address medical and social needs.

Caregiver Support & Education • Provide caregiver coaching, anticipatory guidance, and linkage to community resources.

Safety & Environmental Assessment • Identify home safety risks (falls hazards, medication storage, nutrition access, caregiver strain) and implement mitigation strategies.

Cross-Cutting Responsibilities (Both Settings) • Documentation & Coding • Maintain timely, accurate documentation in the EHR; ensure appropriate billing/coding for clinic and community-based services.

• Quality & Population Health • Participate in quality improvement initiatives (e.g., falls, polypharmacy, avoidable utilization, readmissions, dementia care metrics).

• Communication • Communicate clearly with patients, families, caregivers, and referring clinicians; provide concise care summaries and follow-up plans.

• Compliance & Safety • Adhere to organizational policies, privacy regulations, infection control standards, and community-visit safety protocols.

• Teaching/Leadership (optional) • Mentor learners (residents, fellows, students) and contribute to program development in geriatrics/community care models.

Required Qualifications • MD or DO from an accredited institution • Board Certified/Board Eligible in Geriatric Medicine (or Internal Medicine/Family Medicine with geriatrics expertise), per organizational requirements • Unrestricted medical license (or eligible) in MA • DEA registration (or eligible) • Demonstrated experience with complex older adults, chronic disease management, and interdisciplinary care • Ability to travel for community visits; valid driver’s license as applicable

Preferred Qualifications • Experience in home-based primary care , PACE, SNF/ALF rounding, or complex care management programs • Training/experience in palliative care , dementia care, or transitional care • Comfort with telehealth and remote monitoring tools • Prior quality improvement or program development experience

Core Competencies • Expertise in geriatrics: frailty, multimorbidity, functional decline, cognitive disorders, polypharmacy, falls • Strong clinical judgment in risk/benefit decision-making for older adults • Patient- and family-centered communication; shared decision-making • Team-based care, care coordination, and systems thinking • Cultural humility and commitment to health equity • Organizational skills for mobile/community practice (time, routing, documentation)

Physical & Environmental Demands • Ability to work in outpatient clinical environments and community settings (homes/facilities) • May require standing/walking, transport a medical bag/equipment, and navigating variab

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