High-performing clinics share effective strategies for chronic care follow-up

Background and goal: Regular follow-up visits are critical for managing chronic conditions, yet some primary care clinics achieve higher visit regularity than others. This study aimed to identify specific strategies used by high-performing clinics to promote consistent follow-up visits for adults with chronic conditions​.

Study approach: This qualitative study used semi-structured interviews with 15 primary care physicians, 12 nurses, 15 administrative staff, and 4 pharmacists from 12 clinics-half with high temporal regularity (patients attending follow-ups consistently) and half with low temporal regularity, identifying strategies that helped high–temporal regularity clinics maintain regular chronic care visits​.

Main results: Clinics with high temporal regularity shared key teamwork strategies that distinguished them from low–temporal regularity clinics:

• Close working relationships with less hierarchical staff structures where every team member is part of the decision-making process 

• Staff members described a clear system to ensure follow-up for "no show" patients, beginning with administrative staff reaching out to patients and ending with recruiting the help of patients' family members 

•  Additional innovative strategies, including routine staff meetings, adaptive workflows, assisting patients with bureaucracy, informal communication channels, and consulting social workers

Why it matters: This study highlights how team-based strategies-including structured follow-up systems, proactive patient outreach, and interdisciplinary collaboration-can improve regular follow-up for patients with chronic conditions.