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Delivery System Design:
Make Designated Staff Responsible for Follow-up by Various Methods, Including Outreach Workers, Telephone Calls, and Home Visits
  1. Identify follow-up needs, such as medication refills and symptom monitoring.
  2. Plan the follow-up approach, including who will contact patients, how, and when.
  3. Use phone, outreach workers, and mailings for follow-up.

Tips
  • Ask patients for best methods and times to follow up for check-back visit, pharmacy refills, etc.
  • Develop scripts/algorithms for phone follow-up. This can enable some MAs/HAs/LPNs to perform follow-up usually accomplished by RNs.
  • Track patients lost to follow-up via their case managers.



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