The Geriatrician is responsible for delivering comprehensive, patient-focused medical services to elderly individuals in two main environments: (1) outpatient clinics and (2) community settings. This position is designed to allocate 50% of the time to in-clinic activities (such as evaluations, ongoing management, and consultations) and 50% to community engagements (including home-based primary care, visits to assisted living facilities and skilled nursing facilities, transitional care, and outreach efforts). The clinician will prioritize functionality, quality of life, medication safety, alignment of care goals, and seamless coordination throughout the care continuum.
Work Schedule & LocationSchedule: Full-time, with a 50% clinic / 50% community split
Clinic Location(s):Attleboro, MA
Community Coverage Area:Bristol & Norfolk Counties
Travel: Required for community visits; must possess a valid driver’s license and reliable transportation
On-call:None / Shared rotation / After-hours phone triage
Comprehensive Geriatric Assessment
Conduct thorough evaluations that encompass medical complexity, functional abilities, cognitive health, mood, fall risk, nutritional status, sensory impairments, caregiver support, and social determinants of health.
Chronic Disease Management
Implement evidence-based management strategies for prevalent geriatric conditions such as frailty, dementia, delirium risk, polypharmacy, osteoporosis, urinary incontinence, heart failure, COPD, and diabetes in older adults.
Medication Optimization
Conduct structured medication reviews, deprescribing when necessary, and ensure reconciliation following transitions of care.
Cognitive and Behavioral Health Care
Diagnose and manage conditions such as dementia, mild cognitive impairment, delirium risk, depression, anxiety, and behavioral symptoms in collaboration with caregivers and community resources.
Preventive Care & Risk Reduction
Customize screening and preventive measures based on life expectancy, functional status, patient values, and clinical context; focus on fall prevention and mobility maintenance.
Care Planning & Advance Care Planning
Facilitate discussions regarding care goals; document advanced directives/POLST/MOLST as needed; ensure treatment plans reflect patient preferences.
Consultation & Co-Management
Provide geriatric consultations for complex cases and collaborate with primary care providers and specialists.
Home-Based and Community Geriatrics
Deliver medical services in patients' homes and community settings (e.g., assisted living, adult day programs, supportive housing) for those facing mobility, cognitive, or access challenges.
Post-Acute & Facility-Based Rounding (as applicable)
Conduct continuity visits in skilled nursing facilities (SNFs) or other residential environments, coordinating with facility staff on care plans and safety measures.
Transitional Care Management
Assist with transitions from hospital to home (or SNF to home), ensuring timely follow-up, medication reconciliation, symptom monitoring, and coordination with home health services and caregivers.
Urgent Access & Acute Issue Management (in scope)
Assess and manage subacute changes (e.g., triggers for delirium, falls, dehydration, infection risks) while minimizing unnecessary emergency department visits or hospitalizations when clinically appropriate.
Interdisciplinary Team Collaboration
Work alongside nursing, social work, care management, pharmacy, physical therapy/occupational therapy, behavioral health, and community organizations to address both medical and social needs.
Caregiver Support & Education
Offer coaching to caregivers, provide anticipatory guidance, and connect them with community resources.
Safety & Environmental Assessment
Identify potential home safety risks (such as fall hazards, medication storage issues, nutrition access, and caregiver strain) and implement strategies to mitigate these risks.
Documentation & Coding
Ensure timely and accurate documentation in the electronic health record (EHR); verify appropriate billing and coding for both clinic and community services.
Quality & Population Health
Engage in quality improvement initiatives (e.g., falls prevention, polypharmacy management, reducing avoidable utilization, readmissions, and dementia care metrics).
Communication
Maintain clear communication with patients, families, caregivers, and referring clinicians; provide concise summaries of care and follow-up plans.
Compliance & Safety
Follow organizational policies, privacy regulations, infection control standards, and safety protocols for community visits.
Teaching/Leadership (optional)
Mentor learners (residents, fellows, students) and contribute to the development of geriatrics and community care programs.
MD or DO from an accredited institution
Board Certified/Board Eligible in Geriatric Medicine (or Internal Medicine/Family Medicine with geriatrics expertise), as per organizational standards
Unrestricted medical license (or eligibility) in MA
DEA registration (or eligibility)
Proven experience with complex older adults, chronic disease management, and interdisciplinary care
Willingness to travel for community visits; valid driver’s license required
Experience in home-based primary care, PACE, SNF/ALF rounding, or complex care management programs
Training or experience in palliative care, dementia care, or transitional care
Familiarity with telehealth and remote monitoring technologies
Previous involvement in quality improvement or program development
Expertise in geriatrics: frailty, multimorbidity, functional decline, cognitive disorders, polypharmacy, falls
Strong clinical judgment in making risk/benefit decisions for older adults
Patient- and family-centered communication; emphasis on shared decision-making
Team-based care, care coordination, and systems thinking
Cultural humility and a commitment to health equity
Organizational skills for mobile/community practice (time management, routing, documentation)
Ability to work in outpatient clinical settings and community environments (homes/facilities)
May require standing or walking, transporting medical equipment, and navigating various home environments (stairs, pets, limited space)
Salary Range: $196,992.72 - $313,150.49
Our organization is an equal opportunity employer. We do not discriminate based on race, color, creed, age, gender, sexual orientation, national origin, veteran status, or disability.