Follow Up and Monitor Self-Management Goals for People with Chronic Conditions

Improving Chronic Care: Self-Management Support
  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 action plan. Test follow-up mechanisms (calendar, registry, tickler file) and scripts.
  4. 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.

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