Follow Up and Monitor Self-Management Goals for HIV Patients

  1. Train staff for follow-up.
  2. Test having different staff or volunteers do follow-up.
  3. Schedule follow-up based on dates in the planning tool.
  4. Review and update the planning tool every three to six months.
  5. Test follow-up mechanisms (calendar, registry, tickler file) and scripts.
  6. Include problem solving (a technique to help patients identify problems and develop solutions) in follow-up.
  7. 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)
  • 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. Be mindful of patient confidentiality and ask the patient his or her preferred wording for follow-up messages.
  • Create a laminated card showing graphics of the HAART pills for identification purposes. Include a script on the back for querying patient about adherence.

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