One year ago, InnovAge began a pilot nurse case management position at our PACE center in Aurora, Colorado. What started as an experiment has proven to be a success, and is now being replicated at other InnovAge PACE centers.
Advocating for those most vulnerable
Nurse case managers work within InnovAge’s interdisciplinary care teams to provide extra support for PACE participants who are considered “high-risk,” meaning they struggle with extraordinary health circumstances, frequent emergency room visits, and often don’t have strong family support at home.
Small improvements over time can make a big difference in an older adult’s long-term health. The goal of the nurse case manager is to work proactively with seniors who need additional support in order to stay on-track with their prescribed care plan, out of the emergency room, and safely living in their own homes.
“The nurse case manager develops a unique rapport with participants,” says Aurora Center Director Chad Perkey
. “Having this role at our center has developed a strong sense of connectedness and trust.”
Working with the interdisciplinary care team
Aurora Nurse Case Manager Epi Mazzei sees herself as a coach, educator, and advocate. In her role, she works closely with the entire interdisciplinary care team – coordinating with doctors, specialists, social workers, and caregivers to bridge communication and provide supplementary support.
Epi has a range of experience in nursing, social work, and care management. Her diverse background allows her to approach participant care from both a clinical and social perspective.
“It’s an opportunity to get even more holistic in our day-to-day care,” says Epi. “This role gives me a global perspective, allowing me to be a liaison and connect different teams at the PACE center.”
In addition to developing relationships and monitoring progress, Epi will also meet participants at off-site appointments to make sure external doctors and specialists have all their necessary paperwork – speaking up if the older adult’s needs are not being met.
Expanding the program to serve more seniors
Because of this program’s success in Aurora, InnovAge has now added a nurse case manager role in San Bernardino, California
“Already, our data has shown a successful trend down in repeat hospitalizations and ER visits,” says Regional Executive Director Claudia Estrada. “We’re learning as we go – trying to understand how best to implement this program with our own center and participants.”
The expansion of this nurse case manager role in the San Bernardino PACE center is part of InnovAge’s commitment to finding new and innovative ways to provide the highest possible quality of care for all PACE participants.
“The nurse case manager position represents who we want to be in the community,” says Chad. “It embodies our values: keeping the participant at the center of all we do.”