PDP Handout 3 follow up by 4yb628f


Goal follow up
Goal follow up is a crucial step in ensuring that people who live with long term conditions are
supported to continue increasing their confidence to self manage and enabling them to
maintain progress towards their long term goals.

Goal follow up should occur at a mutually agreed time. For people who have low levels of
confidence to self manage, initial follow up(s) should ideally take place at short time intervals.
Evidence suggests that 14 day follow up is the ideal initial time period that can help people
begin to develop momentum. This is challenging in today’s health care economy and our
systems and ways of working are not always best designed to deliver this.

Examples of methods of follow up may include; text messages, phone calls,            e-mail, peer
support groups, patient internet forums, open drop in sessions.

One smoking cessation services also sends generic motivation text messages to participants
e.g. ‘Congratulations you have been 7 days without a cigarette, keep going, we look forward
to hearing about your progress the next time we see you’.

One group of patients with lung disease have set up a face book peer support group where
they share their goals and support each other. Another group of patients have set up an
interactive e- forum for ideas sharing and problem solving.

Think about how you can effectively follow up on the plans made by your patients, ask your
patients what works best for them.

Think about which members of the team are best placed to deliver follow up and it up can be
provided in a cost effective way. Ensure your team has a shared understanding of the
importance of follow up.

What should be included in the follow up?

What was your action plan for the last week?

How did you get on?

      If, despite problems, the plan was completed, compliment them on being a good self

       If they did not complete the action plan – What challenges did you face? What was
        the problem you encountered? (only ask about problems if the plan was not

       How did you manage the challenges you faced?

       What other ideas did you consider?

       What else?

Use problem solving to look at how the difficulty may be addressed.

Goal follow up                                                                              2/2

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