Weisman Cares
PURPOSE
To provide ongoing support and assistance to patients, their families and caregivers while working with community providers and health care professionals to ensure a smooth transition back to their home and daily routine. Focusing on the social and medical determinates of health, Weisman Cares helps families overcome any social or functional challenges for 15 months after discharge. Monthly reports detailing medication compliance, emergency department visits, hospitalizations or school days missed help keep everyone involved in the patient’s care informed.
CRITERIA FOR ENROLLMENT
Discharge from one of the following programs:
- Diabetes Management
- Pediatric FND & Pain Rehabilitation
- Asthma Management
- Complex Care (patitents requiring in-home nursing)
PROGRAM DESIGN
- Care Team Collaboration: Community physicians and other professionals involved in the patient’s care are notified of enrolment and provided details of program
- Post-Discharge Follow-Up: Patients and families are contacted within 24-72 hours post-discharge to ensure a smooth transition home and address any concerns
- Ongoing Support: Provided to help troubleshoot any point of difficulty impacting the patient's health
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Flexible Communication: Support available via in-person meetings, virtual sessions, or phone calls
- Weekly follow-ups for the first 4 weeks
- Monthly check-ins thereafter
- Contact frequency adjusted based on patient needs
- Continuity of care: Patient status is shared with paediatrician and primary specialist on a monthly basis, other professionals are notified as needed
- Family Choice: Families that choose to enroll may disenroll at any time
POST DISCHARGE FOLLOW UP WITH
- Patient Family/ Caregiver
- Primary Care Physician
- Medical Subspecialties
- Therapies
- Psychology/Psychiatry
- School
- Nursing Agencies
- Any other pertinent entities