Community Project Funding/Congressionally Directed Spending - Non-Construction - The Southern DE Rural Population Health Initiative will expand access to health care and additional community services to 1000 rural DE seniors, enabling their comfortable, safe, aging in place. The Initiative builds on established, successful program foundation; "WeCare", that has been professionally validated to improve health outcomes and render health system cost savings. The WeCare model uses a nurse led model of care referred to as "Personal Health Nursing" which establishes one on one client nurse relationships, wherein the client directs their care and needs, and a nurse advocate provides liaison to primary care, other health services, and community resources. All services are documented in a HIPAA compliant environment, communication and contact between nurse and client is routine, and information sharing with established health provider relationships is fluid. This Initiative will expand capacity through the hire of new personal health nurses, each of whom will interface directly with clients, and cultivated key stakeholder relationships, in targeted population segments including senior centers, health plans, health care providers, and Medicaid. The WeCare program foundation assures consistency of approach across segments, while simultaneously building the relationships and processes that are unique within each targeted new constituency.
