- Perform telemedicine visits to provide patient education regarding chronic conditions.
- Lead exercise sessions for patients over telehealth.
- Assess and triage adult outpatients with multiple chronic conditions, focusing on lung disease and heart failure.
- Coordinate care with primary care providers, specialists, and external care agencies.
- Advocate for patients to improve access to medications, transportation, nutrition, and housing.
- Serve as a continuous point of contact for patients and families across the care spectrum.
- Engage with interdisciplinary teams to optimize care delivery models.