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Long-Term Follow Up Key to Keeping Patients on Track

Jan 21, 2020

Author: Joy Pape, MSN, FNP-C, CDE, WOCN, CFCN, FAADE

The importance of long-term follow up for diabetes and obesity management

A new patient of mine was diagnosed with type 2 diabetes and obesity. We discussed a weight loss treatment to target both her diabetes and obesity, and she followed our mutually agreed upon treatment plan. Things were going well — she would visit every three months and we would reassess and make treatment decision changes as needed. Then, my patient did not visit for two years. When she returned, she had gained back her weight plus a few more pounds, and her blood glucose, blood pressure and lipids were out of her target range….


She told me she had lost her job, lost her benefits, lost a close family member and was under a lot of stress, but the main reason she didn’t return is she did not want to disappoint me. We discussed the importance of visiting when things aren’t going well so we can intervene in a timely manner.

Lessons Learned:

  1. Teach the importance of long-term follow up for diabetes and obesity management from day one.
  2. Understand that many patients want to please their hcp. Teach we won’t be and are not upset with them if things aren’t working out or if they can’t follow the plan. This means we need to reassess and negotiate a new plan, even if this means referring to another health care provider, including social work to help find medical insurance and treatment the patient can afford.
  3. Have a plan to contact those patients who haven’t followed up in a non-confrontational manner. For example, call or have someone from the office call and let them know we’re checking up because we care.


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