We Care Jacksonville Inc

Health & wellness micro-targets uninsured and under-resourced neighbors who reside in duval county zip codes 32233, 32266, 32250, 32082, 32224, and 32227 with a recent inpatient stay at baptist beaches hospital. Objectives: reduce dependence on emergency room care by establishing a primary care medical home; mitigating the significant burden of chronic disease that can mean lost years of productive life; and supporting self-sufficiency. Patients in need of follow-up wound care are also offered both in-clinic and in-home support. The program relies on a certified community health worker, volunteer wound care nurses, a staff rn for clinical support, and funds to support transportation, home medical supplies, and more.

Cancer care cohort - the cancer care cohort, designed for uninsured neighbors facing cancer, provides wrap-around support from diagnosis through treatment, post-treatment surveillance, and beyond. From the support of a dedicated rn case manager to resources to support the social determinants of health - housing, nutrition, transportation, home medical supplies, and more - patients can count on wecarejax to help them face the complex care plan needed. The number of patients with a new diagnosis of cancer in 2023 was 44 - and 106 patients had at least one visit with a medical oncologist.

Jaxcareconnect was developed by the duval safety collaborative (agape health, community health outreach, mission house, muslim american social services, sulzbacher, volunteers in medicine, and wecarejax). During the year ended 9/30/2024, the team processed 2,329 referrals (up 91%). By year end, 47% of new referrals had already established and maintained a primary care medical home with a collaborative clinic. Cases remain open for up to a year to address the social drivers of health that often prevent retention in primary care. Jaxcareconnect evaluation data during the pilot indicated that 60% of patients served do not return to an er for non-emergent care within one year.