Article Figures & Data
Figures
- Figure 1.
Main Characteristics of Staff Contributing to More Regular Follow-Up and Continuity of Care of Patients With Chronic Conditions
Tables
Staff members Doctors Nurses Administrative staff Pharmacists Total Gender Male 11 - 5 3 19 Female 4 12 10 1 27 Settings Low TR 9 7 9 2 27 High TR 6 5 6 2 19 Locality Jewish city/town 10 7 9 4 30 Arab city/town 5 5 6 - 16 Seniority <10 yrs 5 4 4 13 >10 yrs 10 8 11 4 33 Total 15 12 15 4 46 TR = temporal regularity.
General theme Selected quotes Source/high- or low-TR clinic Close staff relationships Our staff is very special. You will not meet many like us. We have amazing interpersonal relationships between us.
We see each other every day. We think highly of each other. We are like a family. We are very close.Nurse/high-TR clinic
Administrator/high-TR clinic“Flat” relationships
Teamwork/complementing each other’s workWe (staff members) believe in joint work. We have the same thinking.
There are patients who relate more to me, there are those who relate to the nurse, and those who relate to the doctor. The doctor will tell me what the patient said because it was easier for him to communicate with the doctor. This could happen to me or the nurse, and then we process with each other.
There is a list for patients with performance levels, we are less involved, it is for the nurse and the doctorAdministrator/high-TR clinic
Administrator/high-TR clinic
Administrator/low-TR clinicPeaceful approach toward challenging patients I tell him (patient), “I know you were busy.” I do not tell him, “We made an appointment, and you didn’t come, you are irresponsible.” I would never tell a patient that he is irresponsible…I tell him no problem, all is well, let’s make a new appointment.
We (doctor and patient) greet each other. We talk and laugh about a joke to clear the air. Then I tell him you need to do this test and so on, and it is in your best interest. We try to convince him.Administrator/high-TR clinic
PCP/high-TR clinicPCP = primary care physician; TR = temporal regularity.
Steps Selected quotes Source/high- or low-TR clinic Step I: Administrative staff prepares the “no show” list and contacts patients who did not proceed with recommended treatments If they (patients) do not show for a week or two, we see their name on the “no show” list and call again. We do not give up. Administrator/high-TR clinic We ask for the report (no show list) and we can see who came and who did not. This huge job is done by the administrator. PCP/high-TR clinic They (doctor and nurse) do not ask me to follow up with patients. The doctor is responsible and he follows. (Clinic Administrator) Administrator/low-TR clinic The doctors are the ones who reach out to patients to explain to them. I can explain administrative things but that is it. (Clinic Administrator) Administrator/low-TR clinic Step II: The nurse reaches out to patients who did not follow-up after the administrator had contacted them It is called perseverance. You take responsibility for patients, and you continue calling. Nurse/high-TR clinic Usually, I nag the patients until they come in. There are patients who do not respond first so I need to nag them several times until they show up. Nurse/high-TR clinic Step III: The PCP contacts patients who still had not followed-up Most patients will respond positively to my request; if they do not follow through after the nurse has tried, they will think, well the doctor bothered calling so let’s try to follow his recommendations. PCP/high-TR clinic The doctor has more influence on the patient. When the doctor tells the patient that he needs him to do this and that and come back, well there is a lot of respect for the doctor, so he (patient) will not say no to the doctor. They respect me too, but with the doctor it is different. Administrator/high-TR clinic I (doctor) prepare the list. I will ask the nurse to follow up. If she contacts the patient the same day, she gets back to me about when he can come in. PCP/low-TR clinic Step IV: The social worker/family member reaches out to patients who still did not follow-up The doctor will try to do what is needed. But sometimes you need to do more, so you ask the social workers to intervene. Especially when there are financial difficulties. PCP/high-TR clinic I had a patient who did not buy the medications, it turned out that he had financial problems, so we involved a social worker and now he receives the medications regularly. Nurse/high-TR clinic If the patient is married, I always ask him to come with his wife. Usually, the wife is the one to handle things. Nurse/high-TR clinic PCP = primary care physician; TR = temporal regularity.
SUPPLEMENTAL DATA IN PDF FILE BELOW
- Khazen_Supp_Table.pdf -
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- Khazen_Supp_Table.pdf -
VISUAL ABSTRACT IN PDF FILE BELOW
- Khazen_VA_Final.pdf -
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- Khazen_VA_Final.pdf -
PLAIN-LANGUAGE SUMMARY
Original Research
Shared Decision Making Among Primary Care Clinic Staff and Family Involvement Improves Follow-Up for Chronic Patients
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:
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Close working relationships with less hierarchical staff structures where every team member is part of the decision-making process
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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
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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.
Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients
Maram Khazen, PhD, et al
Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
Department of Health Systems Management, the Max Stern Yezreel Valley College, Jezreel Valley, Israel
Visual Abstract:
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