Regular follow-up is extremely helpful in motivating self-management and maintaining and tweaking treatment plans. It can also reduce emotional distress and improve patient satisfaction.

Designate Staff to be Responsible for Follow-Up

Choice of staff can be based on staff preferences and communication skills, patient preferences, and available time. See Delivery System Design.

Follow-up can include

1. Checking on progress of self-management goals and action plans.
2. New or ongoing problems.
3. Needs such as eye exam, dental care, HbA1c, labs, and visits.
4. Reminder and preparation for forthcoming clinical visits

Plan the follow-up approach

1. Who will contact patients, how, and when. 
2. Phone, outreach workers, e-mail and mailings can be used for follow-up.
3. A reminder system of some kind for follow-ups is needed.  This can be built into a patient registry (Read More). Or it  can be as simple as filling in names on a “follow-up calendar.”
4. Documentation of follow-up contacts should be placed in patient records. Progress toward patient goals, or their selection of new goals should be documented, so providers can ask about and build on this information. 

Tips for follow-ups

1. Generate reports from the registry to discover those patients in need of follow-up. Such reports should include  contact information, especially if a master contact list isn’t available.
2. Ask patients how often and for best methods and times to follow-up with them for check-back visits, pharmacy refills, etc.
3. Get patient permission to leave phone messages on an answering machine. Some patients do not want any specifics left where others can hear them.