Provide evidence-based management of patients with complex or multiple chronic conditions, including congestive heart failure, COPD and other chronic pulmonary disease, diabetes mellitus, chronic kidney disease, hypertension, cardiovascular disease, frailty, and other diagnoses associated with frequent ED utilization or hospitalization. Working collaboratively with physicians, primary care providers, specialists, care managers, pharmacists, home health, post-acute providers, and community resources, the NP serves as a clinical bridge between the hospital and the patient's next level of care.