Ensure Regular Follow-Up By the Care Team for People with Chronic Conditions

Improving Chronic Care: Delivery System Design
Designate staff to be responsible for follow-up by various methods, including outreach workers, telephone calls, and home visits.
  1. Identify follow-up needs, such as eye exam, dental care, HbA1c, labs, and visits.
  2. Plan the follow-up approach, including who will contact patients, how, and when.
  3. Use phone, outreach workers, and mailings for follow-up.
  • Generate reports from the registry to discover those patients in need of follow-up and generate contact lists.
  • Ask patients for best methods and times to follow-up for check-back visit, pharmacy refills, etc.

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