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.
American Academy of Family Physicians
Journal reference:
Khazen, M., et al. (2025). Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients. The Annals of Family Medicine. doi.org/10.1370/afm.240176.