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About WE care

Empowering Personalized Healthcare and Support

WeCare is a unique nursing service that connects vulnerable older adults in a rural area of Delaware with personalized healthcare support, filling the missing piece in today’s healthcare services by providing ongoing relationships, resource connections, and support during all stages of care.

With highly specialized nurses and secure record systems, WeCare ensures accessible and compassionate care.

History of WE care

The WeCare program was initiated in September 2019 with the primary objective of enhancing the health and well-being of homebound seniors receiving home-delivered meals through the Senior Nutrition Program (SNP). Concurrently, the program aimed to reduce their Medicare costs by providing personalized nursing services. Over the course of the grant, WeCare served 229 seniors from diverse backgrounds. Through over 10,464 phone calls, the program coordinated logistics, addressed social determinants of health, and resolved general living problems while also facilitating medical care coordination and linking clients to necessary services and resources. As evidenced by a review conducted by the University of Delaware, WeCare contributed to the maintenance or improvement of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scores among enrolled seniors. Moreover, preliminary analysis by RealPHN® indicated Medicare cost savings, validating the program’s positive impact.

In the initial phase from September to December 2019, the ACL Innovations in Nutrition Grant “WeCare ServicesTM” was launched in collaboration with five project partners. Operational guidelines and processes were established, and necessary approvals, such as the Institutional Review Board (IRB) approval for human subjects research at the University of Delaware, were obtained. In 2020, the program faced challenges due to the COVID-19 pandemic, necessitating modifications to client enrollment and outreach strategies. Despite these obstacles, WeCare successfully implemented weekly telephone support for enrolled clients and strengthened the foundation of the program.

By September 2020, the program witnessed key developments, including the appointment of Dr. Kemi Sanni as the WeCare ServicesTM Program Coordinator and the assumption of the lead role by EHRI following a transfer application approval. Additionally, a new SNP partner, Modern Maturity Center, was identified, leading to a significant increase in client referrals and enrollments. The year 2021 marked a period of transition and growth for WeCare, with the program addressing a wide range of client needs and experiencing a substantial increase in enrollment and nurse interactions. The maturity phase in 2022 saw WeCare successfully filling gaps and meeting various life circumstances for enrolled clients. Chart reviews conducted by the University of Delaware and an analysis of Medicare cost data further demonstrated the program’s effectiveness in improving client outcomes and reducing healthcare costs.

Throughout its operation, WeCare continued to explore new funding sources, engage with policymakers, and seek opportunities to expand its services, including the implementation of chronic disease self-management education programming. The program remains committed to its mission, striving to meet the ongoing needs of vulnerable seniors and fostering collaboration with key stakeholders in the healthcare landscape.

Partners of WE care

Frequently Asked Questions

Why did you create WeCare ServicesTM?
The percentage of seniors in Delaware is increasing annually. As seniors age, an increasing number wish to “age in place” in their own homes and communities rather than in nursing care facilities. Our organizational leaders have a long history of success compassionately serving seniors within nursing facilities. They and facility staff witnessed a growing need to support seniors outside of the nursing facility, to help avert their unwanted residency. Together with State and local officials, an action plan was conceptualized as a multistakeholder community-based initiative to identify and assist the most vulnerable homebound seniors, to support their health and independent living, in advance and/or instead of, long- term care placement. The project’s name “WeCare” is an extension of the founding partner organization’s mission and vision.
What has been the most effective component of the program?
The union of personal health nursing with an SNP. The ongoing relationship between the WeCare Nurse and individual members provides the “missing piece”; someone, qualified, skilled, and resourced to help resolve and bring resources to individuals well beyond that received in the typical medical care setting. The partnership with a Senior Nutrition Program. A Senior Nutrition Program (SNP) offers numerous economies on which to build and launch a community health service for the most vulnerable older adults in your community. The SNP enjoys an established rapport and trust with the target audience, many times serving as the most frequent form of contact for the homebound senior. The SNP’s alignment with State and Federal programs and policies provides an infrastructure of critical information that can be obtained, with client consent, and without client burden. The infrastructure provides a foundation for qualitative and quantitative research.
What makes WeCare Service’s nursing services unique?
WeCare ServicesTM utilizes an approach called Personal Health NursingTM (PHN). The essence of PHN lies in its person-centered focus of establishing an individual relationship with each client. Weekly communication is maintained by telephone. Client consent enables the PHN to interact with the primary care medical home to facilitate access, adherence, and follow-up to care. Through the ongoing relationship, various needs and problems are identified on which the PHN enacts problem-solving, and creates solutions by identifying and coordinating available community resources.
What qualifications are required for WeCare ServicesTM Personal Health NursesTM?
Aside from a registered nursing degree from an accredited college or university and an active state licensure, the top five (5) characteristics required for a PHN are compassion, trustworthiness, motivation, tenacity, and accountability.
What does an average day look like in the WeCare office ?
Every day is different! Clients are assigned a specific day of the week for a recurring weekly “check-in” phone conversation. That conversation can result in follow-up with the medical community confirming and scheduling appointments, state agencies to apply for benefits and assistance programs, community organizations for transportation and minor home repairs, or pharmacies for prescriptions and durable medical equipment. Sometimes the conversations trigger a need to run an errand, visit the client in the home, or provide indicated feedback to family members or other emergency points of contact. No client’s needs are the same as that of another, and our experience has demonstrated how quickly client needs change and/or shift in priority.
How is client information stored?
WeCare ServicesTM utilizes a proprietary client record system which captures the client demographic information provided by the SNP, and two types of nursing call notes for each client. Call notes are recorded to summarize every nurse encounter with the client. Service notes are recorded, per client, to document various action steps completed with external entities.
What information does the SNP have to store about the client who opts to enroll in WeCare ServicesTM?
The SNP should develop an inhouse system to document which of their clients has been referred to the WeCare ServicesTM program and which have actually enrolled. The former prevents duplication for staff of the SNP. The latter alerts SNP staff that an extra professional resource is available for communicating observations and/or concerns.
What percentage of your annual budget is spent on marketing?
None! Our referrals have come almost entirely from our Senior Nutrition Program partner, and word of mouth from clients served. We have produced some hand out materials that are distributed through the SNP and at client homes.
What has been the most significant expression of physician confidence in WeCare ServicesTM?
A local independent practice family physician closed his practice to retire after twenty- three years of service. He transferred all of his remaining practice medical records (over 1000) to WeCare ServicesTM at the time of closure as means to ensure that his former patients seeking records, many of whom were seniors, would have access to assistance finding a new medical home.
What is a recent client case example that without intervention would have been dramatically different?
There are many. A recent story involved the cooperation of the whole WeCare team to assist a female client in the final stages of life in a local hospital’s Intensive Care Unit (ICU). The hospital would not discharge her due to complex requirements associated with discharge for someone in need of hospice, but without. The WeCare Personal Health Nurse arranged end of life arrangements in coordination with the client, facilitating her hospital discharge, her avoidance of being placed on a ventilation unit, and most important, poignantly honoring a dying woman’s final choices when the client had no one else to assist her.

Chronic Disease Self-Management Program

Equip Yourself with Chronic Disease Education: Empowering Seniors to Take Control

Gain access to essential tools and resources for effectively managing your chronic disease. Chronic Disease Self-Management Education is a proven program tailored for adults facing conditions such as arthritis, asthma, diabetes, lung disease, heart disease, stroke, and osteoporosis. If you find it challenging to navigate your condition and seek effective strategies for self-management, this evidence-based program is designed specifically for you. Take charge of your health and learn practical techniques to enhance your well-being.

One of our helpful staff will assist you through the registration process

Register Today

The Milford Wellness Village

The Milford Wellness Village is an innovative, multi-use development initiative committed to delivering integrated health, education, and other services to the City of Milford, Kent and Sussex Counties, and the State of Delaware. Coordinated services are being provided by a select mix of like-minded organizations and tenants who equally share the desire to improve the health and well-being of area residents and reduce overall costs. The Village has been carefully designed based on interviews with the community. Village components and tenant placement have been determined based on traditional town planning principles and are designed to maximize the user experience.
Learn More

Some Info to Help us Get you Registered.

To support you in registering for our chronic disease self-management programs, we respectfully request that you provide us with some essential information. This information will enable us to register you quickly and efficiently. As soon as we receive your details, one of our staff members will promptly reach out to you.
Thank you.

Some Info to Help us Get you Registered.

To support you in registering for one of our balance programs, we respectfully request that you provide us with some essential information. This information will enable us to register you quickly and efficiently. As soon as we receive your details, one of our staff members will promptly reach out to you.
Thank you.

Some Info to Help us Get you Registered.

To support you in registering for one of our balance programs, we respectfully request that you provide us with some essential information. This information will enable us to register you quickly and efficiently. As soon as we receive your details, one of our staff members will promptly reach out to you.
Thank you.

Some Info to Help us Get you Registered.

To support you in registering for our chronic disease self-management programs, we respectfully request that you provide us with some essential information. This information will enable us to register you quickly and efficiently. As soon as we receive your details, one of our staff members will promptly reach out to you.
Thank you.