Follow Up and Monitor Self-Management Goals for HIV Patients
- 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)
- 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.