Self-Management:
Follow Up and Monitor Self-Management Goals
- Train staff for follow-up.
- Test having different staff or volunteers do follow-up.
- Schedule follow-up based on dates in the planning tool.
- Review and update the planning tool every three to six months.
- Test follow-up mechanisms (calendar, registry, tickler file) and scripts.
- Include problem solving (a technique to help patients identify problems and develop solutions) in follow-up.
- Follow up on adherence goals. If adherence continues to be a problem, consider:
- Increasing the intensity of clinical follow-up
- Shortening the follow-up interval
- Recruiting additional health team members (e.g., chemical dependency counselor, mental health provider)
- Involving friends and family
- Using directly observed therapy (DOT)
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