The team leading the mission.

For eleven years I worked at the place where people leave, and what I learned there is that leaving is almost never simple.

At Temple University Hospital I led discharge planning operations from 2014 to 2025, coordinating a daily workflow of more than three hundred patients with physicians, case managers, social workers, and whatever outside agency might be willing to take the next step with us. Part of that job was fighting for people on paper. I served as the utilization review resource for my team, doing medical necessity reviews, working denials, appeals, and grievances, and handling the escalations nobody else wanted. The goal was always to move people out of the hospital sooner without sending them somewhere that would not hold.

Before Temple I was a Nurse Care Coordinator at Cooper University Hospital with the Camden Coalition, working with the patients who came back through the emergency department again and again because nothing in between had held. I led the case conferences where we put everybody in one room, the hospital, the primary care doctor, the specialists, the managed care plan, and the community organizations, and we stayed there until we had an actual plan instead of a stack of referrals.

And before either of those, I was at the bedside. I spent years as an LPN in sub acute rehabilitation and long term care at St. Mary's Catholic Home, caring for older adults and people living with disabilities, teaching families what to do once their mother came home, and mentoring the new nurses coming up behind me. That work is still the foundation of how I think about all of this.

Because the people I have cared for were never only one thing. Some were sleeping outside or one missed payment away from it. Many were carrying a mental illness or a substance use disorder on top of a chronic medical condition, and those two things were almost never treated by the same team or even in the same building. Some were older adults and people with disabilities being sent back to homes that could no longer keep them safe. Some were young people aging out of foster care at eighteen with a file about to be closed and no one left to call. We call it homelessness at the end, but by then it has usually been five or six other things first.

That is the part I could never make peace with. The services exist. Delaware has good programs and good people running them. What fails is everything in between them. A person leaves with a folder full of referrals and within a week there is no one responsible for whether any of it actually happened.

When Dr. Maxwell and I first sat down together, he said something I have not been able to put down since. Collaboration is the cure. He believes that what breaks most people is not a missing service but a missing connection between services, and that you cannot treat a person in pieces and expect the pieces to add up to a well person. Whole person integrated care is not a program to him. It is the entire premise of what he has built. Medical, dental, behavioral health, and housing at one table, looking at one person, working from one plan.

I have spent my whole career building that table by hand, one case conference and one patient at a time, and then watching it come apart the moment the meeting ended. What drew me to Harmony Health is that here the table does not come apart. Prevent, Restore, Transition is not a tagline to me. It is a promise that somebody stays with a person the whole way, and not only for the part that falls inside their own job description. I have seen what happens when that promise is kept for one patient. I accepted this role because I want to find out what happens when it is kept for a community.

Delaware is not new to me, either. My mother has lived here for decades, and I earned my Bachelor of Science in Behavioral Science at Wilmington University. The neighborhoods we serve are neighborhoods I know, and the people we serve are people I have lived beside and cared for most of my life.

We will be measured on our outcomes, and we will publish those measures before the first participant walks through our door. I want it that way. It is how you tell the difference between an organization that is helping people and one that is simply busy.

I am honored to be part of this work.