High-performing clinics use teamwork for chronic care follow-up

Regular follow-up visits are essential for managing chronic conditions like diabetes and heart disease. However, some primary care clinics are better at getting patients to return for these visits than others. Researchers studied this issue to discover strategies that successful clinics use. They held interviews with 46 healthcare professionals from 12 clinics. Half of these clinics had a high rate of patient follow-ups, while the other half had lower rates. The findings showed that clinics with high follow-up rates had strong teamwork and communication. Staff members worked closely together and valued everyone's input. This included roles from doctors, nurses, administrative staff, and pharmacists. One key strategy involved reaching out to patients who missed appointments and making sure they rescheduled. Administrative staff often contacted these patients directly and sometimes involved family members in the process to encourage follow-ups. Other successful strategies included regular meetings among staff, flexible workflows, and assistance for patients dealing with health care paperwork. Clinics also used informal communication and collaborated with social workers to help patients. The study underscores the importance of teamwork and structured systems in improving follow-up care for patients with chronic conditions.