Follow Up and Monitor Self-Management Goals for People with Chronic Conditions
Improving Chronic Care: Self-Management Support
- Train staff for follow-up.
- Test having different staff or volunteers do follow-up.
- Schedule follow-up based on dates in the action plan. 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.
- Don't skip follow-up; patients will think you don't care.
- Make sure patients determine the follow-up date and method.
- Follow-up can be by phone, email, fax, home visit, clinic visit, etc. Use trained, culturally competent lay people for follow-up.