Advanced Practice Provider - Chronic Disease Management
Summary of Essential Functions
Provides comprehensive acute and chronic patient care across inpatient setting
Assesses patient health status and determines diagnostic and therapeutic needs
Documents patient information accurately within the medical record
Educates patients and families to support continuity of care
Collaborates with physicians and interdisciplinary teams
Acts as a liaison between providers, hospital, and community
Educational Requirements
Licenses and Certifications
Meets Texas Board requirements for Advanced Practice Nurses or Physician Assistant
Current prescriptive authority (DEA/DPS as applicable)
National certification as an Advanced Practice Nurse or Physician Assistant
ACLS/PALS preferred
Knowledge/Skills/Abilities
Clinical experience preferred
Strong critical thinking skills
Completion of hospital orientation requirements
Physical Requirements
Ability to stand for extended periods and perform clinical tasks
Ability to lift up to 50 pounds
Ability to work in high-stress environments
Exposure to bloodborne pathogens
Duties and Responsibilities
- Conduct comprehensive patient assessments, including medical history, physical examination, and review of diagnostic data to guide clinical decision-making
- Develop, implement, and adjust individualized, evidence-based care plans in collaboration with the interdisciplinary team and supervising physician as required
- Provide patient and family education to improve understanding of disease processes, treatment plans, and expected outcomes
- Document all patient encounters accurately and timely in the electronic medical record (e.g., EPIC), ensuring compliance with regulatory and organizational standards
- Collaborate with physicians, nursing staff, case management, social work, and other disciplines to ensure coordinated, patient-centered care
- Perform palliative care consultations for patients with life-limiting illnesses
- Lead and support goals-of-care discussions, including advance care planning and code status clarification
- Assess and manage complex symptom burden
- Deliver compassionate, comfort-focused care for patients designated as comfort care, ensuring symptom relief, dignity, and alignment with established goals of care
- Provide emotional support to patients and families
- Coordinate care with hospice and community palliative resources
- Manage inpatient diabetes care, including glycemic control and insulin titration
- Utilize clinical tools (e.g., EndoTool) to support insulin management
- Collaborate with nursing on insulin and glucose monitoring practices
- Address barriers to glycemic control
- Coordinate discharge planning and outpatient referrals
- Facilitate transitions of care and communicate with outpatient providers
- Participate in interdisciplinary rounds and discharge planning
- Identify high-risk patients and implement interventions
- Provide staff education and support when needed
- Participate in program development and workflow improvement
- Serve as a clinical resource and mentor
- Contribute to quality improvement initiatives and monitor key metrics
- Maintain licensure and certifications
- Adhere to scope of practice and agreements
- Uphold confidentiality and professional standards
- Performs all other tasks/responsibilities as necessary