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.
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.