Transforming primary care: The role of teamwork in patient follow-ups

New study explores how primary care teams can encourage regular follow-up visits for patients with chronic conditions. By comparing clinics that achieve more- and less-regular follow up visit patterns for such patients, the research highlights the importance of teamwork, flat relational dynamics, and proactive systems such as patient outreach and social worker involvement in achieving more regular care patterns for patients with chronic conditions. The findings suggest that fostering collaboration and adaptability among staff can significantly improve patient engagement and long-term health outcomes.

A new study led by Dr. Maram Khazen from The Max Stern Yezreel Valley College and Prof. Adam Rose from the Faculty of Medicine at the Hebrew University of Jerusalem sheds light on how primary care teams can encourage more temporally regular (TR) follow-up visits for patients with chronic health conditions. Published in the Annals of Family Medicine, the research identifies strategies that foster effective teamwork and proactive care delivery, emphasizing the potential to improve patient outcomes. The research was conducted with the participation and partnership of Leumit Healthcare Services and the Leumit Research Institute.

The study involved semi-structured interviews with 46 healthcare professionals, including physicians, nurses, administrative staff, and pharmacists, from 12 primary care clinics in Israel. Half of the clinics were identified as high-TR, where patients maintained regular follow-ups, while the others were low-TR. By analyzing their findings, the researchers uncovered several key factors that contribute to the success of high-TR clinics.

Among the most effective strategies were having structured systems in place to encourage follow-up, beginning with administrative staff reaching out to patients and extending to involving family members in care. Clinics with regular follow-up visits also emphasized teamwork and flat relationships between staff, rather than rigid hierarchies. Regular staff meetings, adaptive workflows, informal communication channels with patients, and coordination with social workers also played a critical role in ensuring continuity of care.

Dr. Maram Khazen commented, “This study demonstrates that the relational dynamics among healthcare staff are as important as their clinical expertise. When staff work together as a cohesive team, they create an environment that supports patients more effectively and fosters trust, encouraging them to remain engaged in their care.”

Prof. Adam Rose added, “The findings highlight the importance of multidisciplinary collaboration in primary care settings. By fostering a culture of teamwork and adaptability, we can significantly improve the long-term health outcomes for patients with chronic conditions.”

This research underscores the need for a high-functioning, multidisciplinary approach in primary care settings to proactively manage chronic illnesses and reduce the risk of complications. By focusing on teamwork and innovative care strategies, clinics can transform patient engagement and improve the delivery of care.