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.
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
Requirements
Experience in home-based primary care , PACE, SNF/ALF rounding, or compl
Benefits
Health insurancePaid time off
Additional Information
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
Sturdymemorial · Attleboro, MA