Advanced Practice Provider - Chronic Disease Management
Summary of Essential Functions
Provides comprehensive acute and chronic patient care across inpatient setting
Independently evaluates and manages patients within APP scope of practice
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
Work between the hours of 7a and 7p with weekend/holiday rotation
Educational Requirements
Licenses and Certifications
Current Texas Licensure Nurse Practitioner or Physician Assistant (PA)
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Eligible to obtain prescriptive authority (DEA/DPS as applicable)
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National certification as and Advanced Practice Nurse or Physician Assistant
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ACLS/PALS preferred
Knowledge/Skills/Abilities
Clinical experience preferred
Experience in palliative care, hospice, internal medicine, hospital medicine, endocrinology or critical care preferred
Strong critical thinking skills
Completion of hospital orientation requirements
Excellent verbal and written communication skills
Commitment to patient-centered, compassionate care
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
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Conduct comprehensive patient assessments, including medical history, physical examination, and review of diagnostic data to guide clinical decision-making
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Develop, implement, and adjust individualized, evidence-based care plans in collaboration with the interdisciplinary team and supervising physician as required
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Maintain compliance with applicable Texas Medical Board and Texas Board of Nursing supervision/collaborative agreements and regulatory requirements including periodic face-to-face meetings with supervision physician and documentation of chart review as required
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Provide education to patients, families and interdisciplinary team members on disease management, symptom control and goals of care.
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Document all patients encounters accurately and timely in the electronic medical record (e.g., EPIC), ensuring compliance with regulatory and organizational standards
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Collaborate with physicians, nursing staff, case management, social work, and other disciplines- and participate in interdisciplinary rounds as needed- to ensure coordinated, patient-centered care
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Perform palliative care consultations for patients with life-limiting illnesses
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Lead and support goals-of-care discussions, including advance care planning and code status clarification
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Assess and manage complex symptom burden
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Deliver compassionate, comfort-focused care for patients designated as comfort care, ensuring symptom relief, dignity, and alignment with established goals of care
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Participate in quality improvement initiatives focused on clinical outcomes, patient experiences and cost-effective care
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Provide emotional support to patients and families
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Coordinate care with hospice and community palliative resources
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Manage inpatient diabetes care, including glycemic control and insulin titration
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Utilize decision support clinical tools (e.g., Endo Tool) to support insulin management
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Collaborate with nursing on insulin and glucose monitoring practices
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Identify and address barriers to glycemic control
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Coordinate discharge planning and outpatient referrals
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Facilitate transitions of care, including appropriate referrals and communication with outpatient providers
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Participate in interdisciplinary rounds and discharge planning
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Identify high-risk patients and implement interventions
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Provide staff education and support when needed
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Participate in program development and workflow improvement
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Serve as a clinical resource and mentor
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Contribute to quality improvement initiatives and monitor key metrics
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Maintain licensure and certifications
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Adhere to scope of practice and agreements
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Uphold confidentiality and professional standards
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Performs all other tasks/responsibilities as necessary
