Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients

Dear Editor,

We read with great interest the recent article by Khazen et al. (1) on teamwork among primary care staff to achieve regular follow-up of chronic patients. This is a valuable contribution to the literature on continuity of care and proactive management of chronic conditions. The study brings forward a set of strategies that have the potential to guide improvements in primary care systems internationally. As family physician researchers in Spain, we find the topic of particular relevance given the extensive work done in our country to promote integrated, patient-centered chronic care models. Drawing on national strategy documents and regional plans, specifically the Estrategia para el Abordaje de la Cronicidad en el SNS (2) and the Plan Estratégico de la Subdirección General de Continuidad Asistencial de Madrid (3), we wish to offer some reflections that we believe complement and further contextualize the findings by Khazen et al.

One of the most compelling findings of the article is the role of cohesive, non-hierarchical teams in promoting regular follow-up. This resonates strongly with Spain's approach to team-based care, as expressed in both the national strategy on chronic care and the regional strategies implemented in Madrid and other autonomous communities. These plans emphasize interprofessional collaboration, including nurses, social workers, administrative staff, and primary care physicians, with clear role delineations and shared goals. The Madrid plan, for instance, establishes the role of the *Director de Continuidad Asistencial* in every hospital and promotes a networked approach with coordination roles clearly defined across care levels(3). The Spanish system is thus already organized to support the kind of flat, team-based models Khazen et al. found effective.

We also recognize the importance of systematic follow-up processes and communication structures. Khazen et al. emphasize proactive identification and outreach to patients who miss appointments. The Spanish national strategy likewise promotes proactive, structured follow-up through electronic health records (EHRs), risk stratification tools, and individualized care plans. The *Estrategia de Cronicidad* explicitly promotes tools like the GMA (Grupos de Morbilidad Ajustada) for patient stratification and targeting interventions(2). These approaches help align care frequency and intensity with patient needs, thereby supporting the regular follow-up patterns Khazen et al. describe.

Informal communication channels such as WhatsApp, also highlighted in the article, have become increasingly popular in Spain as well, particularly during and after the COVID-19 pandemic. Nonetheless, Spanish strategic documents call for caution and regulation in the use of digital communication tools, emphasizing the importance of data security, traceability, and equitable access(2). Thus, while direct messaging can enhance accessibility and engagement, these tools must be embedded within structured, ethically governed frameworks.

Khazen et al.'s description of routine, interdisciplinary team meetings is another area where Spanish policy aligns. The *Plan Estratégico de la Subdirección General de Continuidad Asistencial* advocates regular, formalized meetings involving professionals across care settings to review patient progress and ensure continuity(3). Such meetings are not merely organizational tools—they are vehicles for reinforcing team identity, shared responsibility, and collective problem-solving. They also provide opportunities to align medical, nursing, administrative, and social perspectives on care plans.

A particularly valuable insight from the article is the emphasis on the administrative staff’s contribution to chronic care management. This group is often overlooked in care planning, yet in both the Khazen study and Spanish practice, they are shown to play a pivotal role in facilitating access, organizing appointments, and reinforcing follow-up protocols. In Spain, administrative professionals are increasingly recognized as first-line agents in patient navigation and continuity of care, as reflected in strategic recommendations to improve their training and integrate them into patient management pathways(2).

Social workers are likewise instrumental in Spain’s chronic care model, and their inclusion in multidisciplinary teams aligns directly with Khazen et al.’s findings. The national strategy stresses coordination between health and social services, aiming to address determinants such as housing, financial insecurity, and caregiving burdens. Regional strategies like that of Madrid explicitly include social care considerations in integrated care pathways and advocate shared access to social and clinical records where feasible(3).

In relation to structural factors, Spain’s implementation of EHRs and information systems stands out. Most autonomous communities have established interoperable systems, allowing professionals at different care levels to access shared patient records. Madrid’s HORUS platform, for instance, allows viewing of clinical data across hospital and primary care settings, and the national *Estrategia de Cronicidad* calls for further digital integration(2)(3). This infrastructure supports many of the coordination functions that Khazen et al. attribute to high-performing clinics.

Although Spain has generally not relied on individual performance incentives like those described in Khazen’s study, regional contracts increasingly include quality indicators related to follow-up and continuity. The Madrid strategy emphasizes performance monitoring and makes reference to contracts-programa that measure coordination and follow-up indicators as tools to evaluate team functioning and incentivize organizational learning(3).

Finally, patient empowerment is an area where Spain has made substantial progress. The Red de Escuelas de Salud para la Ciudadanía (Citizen Health Education Schools Network), supported by the Ministry of Health, is a national initiative designed to promote health literacy and self-care among chronic patients(2). Educational interventions are seen as essential complements to clinical strategies and are often led by nursing staff, sometimes with peer educators. These initiatives help patients become active participants in their care and reinforce the collaborative, ongoing engagement that Khazen et al. identify as key to temporal regularity.

In our opinion, Khazen et al.'s work offers timely and meaningful insights into the organizational dynamics that foster effective follow-up for patients with chronic conditions. Our perspective from the Spanish context, grounded in both national and regional strategies, suggests that many of these elements—interdisciplinary teamwork, structured follow-up systems, social care integration, digital tools, and patient engagement—are not only transferable but already partially operationalized within our system. There is much to be learned from international comparisons, and we believe future studies could deepen this dialogue by including evaluations of implementation fidelity and patient perspectives, as well as further exploring the role of structural supports such as digital health and community partnerships.

REFERENCES:

1. Khazen M, Shalev L, Golan-Cohen A, Merzon E, Israel A, Vinker S, et al. Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients. Ann Fam Med. 2025 Mar 1;23(2):100–7.

2. Ministerio de Sanidad. Estrategia para el Abordaje de la Cronicidad en el Sistema Nacional de Salud: Informe de evaluación y líneas prioritarias de actuación [Internet]. Madrid: Ministerio de Sanidad; 2021. Available from: https://www.sanidad.gob.es/organizacion/sns/planCalidadSNS/pdf/Evaluacio...

3. Consejería de Sanidad de la Comunidad de Madrid. Plan Estratégico de la Subdirección General de Continuidad Asistencial en la Comunidad de Madrid 2018-2021 [Internet]. Madrid: Servicio Madrileño de Salud, Consejería de Sanidad; 2018. Available from: https://www.comunidad.madrid/sites/default/files/doc/sanidad/plan_estrat...