The clinic care manager will also be the nurse case manager for an assigned panel of participants, responsible for comprehensive nursing assessment, care planning and effectuation, care coordination across settings (PACE center, home, contracted providers, hospital/SNF), and proactive management of chronic conditions to support participant safety, independence, and quality of life. To address these gaps, we've found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve.