Key Responsibilities

1. Inpatient Clinical Management

• Provide daily evaluation and management of hospitalized patients requiring palliative, metabolic, or geriatric co-management.
• Conduct comprehensive assessments including functional status, frailty, nutritional risk, symptom burden, and goals of care.
• Develop and implement individualized care plans in collaboration with surgical and interdisciplinary teams.
• Manage acute and chronic symptoms such as pain, dyspnea, nausea, delirium, and anxiety using evidence-based approaches.
• Optimize metabolic and nutritional status, including coordination of enteral/parenteral nutrition, glucose management, and micronutrient support.
• Lead geriatric-focused interventions such as delirium prevention, mobility protocols, medication reconciliation, and polypharmacy reduction.

2. Palliative Care Integration

• Facilitate goals-of-care discussions, advance care planning, and shared decision-making with patients and families.
• Provide primary palliative care support for symptom management and psychosocial needs.
• Identify patients who require specialty palliative care consultation and coordinate referrals.
• Support transitions of care, including hospice referrals when appropriate.

3. Outpatient Pre-Operative Optimization Clinic

• Conduct comprehensive pre-operative evaluations for frail, high-risk, or medically complex surgical patients.
• Perform frailty assessments, functional evaluations, nutritional screening, and metabolic risk stratification.
• Identify modifiable risk factors and develop individualized optimization plans (nutrition, mobility, glucose control, medication adjustments, symptom management).
• Lead shared decision-making conversations that integrate surgical risk, patient goals, and expected recovery trajectories.
• Coordinate referrals to geriatrics, cardiology, pulmonology, nutrition, palliative care, or other specialties as needed.
• Educate patients and families on perioperative expectations, enhanced recovery pathways, and postoperative support needs.
• Collaborate with surgeons and anesthesiology to determine surgical readiness and align on risk-mitigation strategies.
• Track optimization metrics and postoperative outcomes to support continuous improvement.

4. Surgical Co-Management & Perioperative Optimization

• Partner with surgical teams to identify high-risk patients pre- and post-operatively.
• Implement evidence-based protocols for frailty assessment, enhanced recovery, and metabolic optimization.
• Monitor postoperative complications and intervene early to prevent decline.
• Participate in multidisciplinary rounds, case conferences, and care coordination meetings.

5. Communication & Family Support

• Serve as a consistent point of contact for families navigating complex surgical hospitalizations.
• Provide clear, compassionate updates and education regarding prognosis, treatment options, and expected recovery trajectories.
• Support culturally sensitive communication and shared decision-making.

6. Interdisciplinary Collaboration

• Work closely with surgery, geriatrics, palliative care, nutrition, PT/OT, case management, and nursing.
• Promote a team-based approach that centers patient dignity, functional recovery, and quality of life.
• Participate in care pathways and clinical protocols that integrate metabolic and geriatric principles into surgical care.

7. Quality Improvement & Clinical Excellence

• Contribute to departmental QI initiatives related to frailty, delirium, nutrition, readmissions, and end-of-life care.
• Track and report clinical outcomes, documentation quality, and adherence to care pathways.
• Participate in morbidity and mortality reviews, geriatric surgery initiatives, and palliative care quality metrics.

7. Education & Professional Development

• Provide education to medical students, residents, fellows, and nursing staff on palliative, metabolic, and geriatric principles.
• Stay current with evolving evidence in perioperative geriatrics, palliative care, and metabolic optimization.
• Participate in departmental teaching conferences and continuing education.

Qualifications

• Master's degree from an accredited NP or PA program.
• National certification and state licensure as an NP or PA.
• Experience in palliative care, geriatrics, hospital medicine, or surgical co-management preferred.
• Demonstrated skill in complex communication, interdisciplinary teamwork, and high-acuity inpatient care.
• Commitment to patient-centered, culturally responsive care.