After-Visit Follow Up by Non-Clinicians

After-Visit Follow Up by Non-Clinicians
Blueprint CMP Implementation Guide 
Quick Start Guide
Practice Facilitation Guide
Purpose of This Guide
This guide is designed to help quality improvement (QI) coaches support primary care practices in implementing and enhancing post-visit follow-up processes by non-clinicians. These follow-up processes are proven to improve patient engagement and health outcomes, particularly for those with chronic diseases like diabetes.
How to Use This Guide
This guide provides a step-by-step approach for integrating after-visit follow up by non-clinicians into a practice’s workflow. Each section outlines specific tasks QI coaches can guide practices through, with practical worksheets to help with planning, decision making, and monitoring progress.
CMP Description: After-Visit Follow Up by Non-Clinicians
Strong relationships with patients living with diabetes are associated with better outcomes. After-visit follow up by non-clinicians, the care management process (CMP) that is the focus of this guide, can be an important tool for building these relationships, help ensure patients adhere to care plans, and help patients receive support to maintain their health between visits.
After-visit follow up provides proactive, personalized outreach that can help patients feel cared for and supported between visits—reinforcing adherence to care plans and strengthening their connection and relationship with their primary care provider (PCP). After-visit follow up by non-clinicians can include checking whether medications were filled, if tests are due, if the recommended care (such as referrals or lab tests) was completed, and if barriers to care were addressed.
It can also help ensure patients are able to address any concerns they had during the visit and assess whether they were satisfied. Both of which support better patient experience, care, and outcomes and strengthen the provider-patient partnership.
Proactive follow-up goes beyond passive methods like sending portal messages or generic reminders. Follow-up should be active and tailored to each patient’s needs. Providing tailored support, education, or reminders, or offering assistance to address barriers, shows a commitment to patient care that automated-only systems alone cannot achieve.
Active, individualized follow-up reinforces the message that their care matters and improves adherence, patient retention, and ultimately, their health outcomes.
After-visit follow up by non-clinicians can be delivered by medical assistants (MAs), care coordinators, health coaches, social workers, community health workers, and administrative staff. The method and approach should align with the practice’s reasons for implementing the CMP.
Types of after-visit follow up include:
Routine post-visit follow-up based on medical note. You may ask:
Your PCP said you needed the following done, were you able to do this? Or do you need assistance doing this?
Is there anything you were not able to ask your PCP you would like me to convey?
Were you happy with the visit?
Care plan check-ins
Medication-related follow up
Preventive care services and tests due follow up
Health coaching and self-management follow up
Behavioral and lifestyle follow up
Social determinants of health follow up
Care coordination referral follow up
Rationale for the Selection of This CMP
After-visit follow up by non-clinicians was identified in the UNITED study (Peterson et al., 2019) as one of three CMPs out of 64 that were associated with higher performance in the delivery of diabetes care and improved health outcomes.
Benefits of This CMP
Improved continuity: Helps patients remain engaged with their care team and care plans, necessary lab tests, follow-up appointments, and preventive services.
Stronger patient relationships: Builds trusting relationships with patients to support greater adherence to care recommendations and proactive self-management.
Addresses barriers to care: Identifies and mitigates social and logistical barriers (e.g., transportation and medication costs) that may prevent patients from completing referrals, engaging in self-management activities, and following their care plans.
Supports full engagement of care team and staff: Assigns follow-up tasks to non-clinicians, freeing clinician time for complex care tasks, increasing efficiency, and reducing clinician burnout.
What Good Looks Like for This CMP
CASE EXAMPLES
As a practice facilitator (PF) or PCP implementing or enhancing CMPs in a practice, knowing what “good” looks like can help you implement CMPs more effectively and efficiently. Case examples are contributed by PFs like you and practices that have developed exemplary processes and protocols for this CMP.
PEARLS
PEARLS are contributed by PFs and their practices. This is a dynamic list of lessons learned can be used to enhance your CMP process, avoid common pitfalls, and refine your and your practice’s processes. Read or submit case examples or PEARLS for CRs.
Key Tasks
Start with Practice Leadership
Before you begin implementing this CMP, meet with practice leadership to confirm their buy-in and what they want to accomplish. Ask leadership to identify the practice champion for this CMP you will work with throughout the project.
Form the CMP Project Team
Work with the CMP champion and practice leadership to create a project team for design and implementation. The team should include representatives from all relevant roles in the practice, including:
Front desk: Clerks may be responsible for collecting updated contact information from patients and their communication preferences which will be important in the follow-up work.
MAs: MAs may be responsible for carrying out follow-up processes.
Clinicians: Clinicians will know which patients are most in need of follow-up and may prioritize these patients to receive after visit follow-up. They may also handle escalations.
Community health workers, health coaches, care coordinators, and managers: They often play key roles in supporting patients between visits.
IT or electronic health record (EHR) specialists: They will help the practice determine how they may want to automate different parts of follow-up processes using existing or new HIT resources, and assist in configuring these actions and maintaining them.
Some questions to ask the practice as they decide on the team are:
Who in our practice is interested in or passionate about strengthening relationships with patients between visits?
Who could serve as the champion for this CMP if not already identified?
Who in our practice has experience with after-visit follow up and keeping patients engaged with care between visits?
Which disciplines and staff will be involved in the after-visit support activities and should be included on the team?
Who will help with the information systems and reports we will need to trigger and track between visit follow-up actions?
Use the​ ​CMP Project Team Worksheet to document who will be on the team.
Task 1. Review and evaluate the current after-visit follow-up processes.
Work with the practice to assess the current state of their after-visit follow-up processes.
​Use the ​ Informal assessment tool​ or create your own.
Task 2. Set goals for adding after-visit follow up by non-clinicians.
Use the results of the assessment completed for Task 1 and work with the practice to identify which after-visit follow-up processes they want to implement or improve. Work with them to identify their reasons for implementing each chosen process, how they will measure their set goals for each process, and how they will determine they have attained them.
Use this  Goal Sheet  or create your own.
Task 3. Develop a high-level design for the after-visit follow-up process and map processes.
Work with them to create a high-level process map of a first after-visit follow-up process. If the practice wants to implement multiple after-visit follow-up processes, help them decide which process they will start with. This might be the one they ranked as the highest priority on their goal sheet or the one that is the easiest for them to implement.
Starting with “easy” processes first can be a good way to help staff and clinicians in a practice build confidence in their ability to successfully design and implement changes—and a good way for them to attain a quick win.
Use a scenario-based design approach to help the practice identify the key elements of the process they want to implement. For scenario-based design, the practice creates an ideal scenario, or several scenarios, that illustrate how an ideal after-visit follow up would look. This becomes the basis for creating an initial design for the process they want to implement.
Instructions for Scenario-Based Process Design
Tips for facilitating the session:
Keep the discussion focused on patient-centered outcomes.
Encourage participation from all team members to gain diverse perspectives.
Emphasize that the scenario is a starting point and can evolve as the process is tested and refined.
Step 1: Explain scenario-based design.
Begin the session by introducing the concept of scenario-based design: A method where the team develops ideal scenarios of how a process should look. These scenarios act as a foundation for creating the process map and implementing improvements.
Step 2: Brainstorm ideal follow-up scenarios.
a) Ask the participants create a patient scenario that includes the ideal implementation of the follow-up process they want to implement (or improve).
b) Ask:
Who is the patient?
How old are they?
What triggers the follow-up?
Who conducts the follow-up?
Are others involved in the follow-up process? If so, who? How do they receive information from the process initiator?
What tools or resources are used for the process to run smoothly?
How does the larger team know the process has been initiated with a patient?
How does the larger team know where the patient is in the process?
How do we know we attained our goal for the process with the patient?

Capture detailed scenarios on a whiteboard or shared document as the practice crafts it.
Example scenario:
After her recent clinic visit, Ms. Garcia, a 64-year-old woman living with type 2 diabetes, received a follow-up call from the medical assistant (MA). The MA reviewed her medical note, which included scheduling an eye exam and refilling her medication. The MA asked whether she had any questions for her care team after the visit, if she was able to schedule her eye exam, and if she was able to get her prescription filled. During the call, Ms. Garcia shared she hadn’t scheduled the exam due to confusion about how to do it. The MA provided the contact details for a local optometrist who provides comprehensive diabetes eyes exams and offered to assist her with calling and scheduling. Additionally, Ms. Garcia mentioned mild dizziness after starting the medication her primary care provider (PCP) prescribed and indicated her husband told her to stop taking it. The MA documented this information and the follow-up support in Ms. Garcia’s record and escalated her concern about medication side effects via secure message to her PCP.”
Step 3: Create a high-level process map based on the scenario.
Once the team has created an ideal scenario or story about the specific follow-up process, work with them to translate that scenario into a high-level process map.
Step 4: Consider the timing of the follow up.
Consider the timing for the follow up and the rules the practice will use to determine this timing.
Review the different models for determining timing.
Step 5: Have the team add roles, responsibilities, and resources needed at each step in the high-level map.
a) Following the adage, “the person that owns the process holds the pen,” engage the non-clinician staff that will be conducting the follow-up in the next phases of the design process.
b) Add the roles, responsibilities, and resources needed at each step.
c) Refine the process map and expand to a swim-lane showing the roles of multiple team members, if indicated.
Step 6: Identify any barriers to implementing the ideal scenario workflow and refine the process to accommodate/address them.
Work with the team and staff who will be conducting the follow-up to identify potential barriers to implementation of the new process. Incorporate this information into the workflow design and resource checklist.
By guiding the practice through this method, you help create a practical, patient-focused follow-up process tailored to the team’s goals and resources.
Use this worksheet this worksheet or a workflow mapping tool like LucidChart available online to help the practice document it’s ideal scenario and also document resources and barriers. Complete it as many times as needed depending on the number of distinct follow-up processes being implemented or enhanced.
Task 4. Confirm there are adequate staffing resources available to implement the new process.
Work with the practice to identify which staff will support the after-visit follow-up process and calculate the time needed to carry out the tasks.
How many follow-up calls will they need to make weekly?
What is the estimated average time needed for each call?
How much time will it take for them to gather the information they need in order to make the calls and who will do this (e.g., create call lists)?
How much time does it take for them to provide follow-up information to patients? Escalate to PCP?
How will they document the calls and how much time will this require?
How much time will it take for them to conduct second outreaches to patients who require it?
What competing demands might interfere with their ability to complete this new process?
What training needs will staff have?
What additional resources beyond those on the checklist in Task 3 do staff believe they will need?
Can technology, such as automated reminders or EHR features, be used to offset any human resource gaps or reduce time required by non-clinical staff to carry out these new tasks?
Will more staff hours or new hires be necessary?
Here is an example of a table for calculating the amount of staff time that is required for a follow-up process.
Sample Table for Estimating Process Time Requirements
​Use ​this worksheet to help a practice estimate the amount of time the new process may require and make adjustments to ensure they have sufficient resources.
Task 5. Create a list of resources needed to implement the after-visit follow-up process and create or engage them.
For this task, work with the practice to create a list of the resources they would need to implement the process, assess the availability of the needed resource, and either develop or engage the needed resource. Below is a sample resource list based on the scenario about Ms. Garcia presented earlier in this document.
HIT and tracking resources the practice may want to inventory and consider engaging include items such as:
Automated reminders for a patient about follow-up actions, such as scheduling an eye exam or attending a diabetes management class.
Customizable worklists that enable staff to track patients flagged for follow-up calls after visits, hospital discharges, or emergency room visits.
Communication tools such as SMS, secure messaging, or a portal that clinical staff can use for after-visit follow up.
Automated task creation based on provider notes that non-clinical staff can use to guide the content of the outreach.
Trigger alerts for staff to contact patients if specific actions, such as labs or medication adjustments, remain incomplete.
Integrated call scripts and call prompts or checklists to ensure all relevant topics are covered (e.g., "Did you fill your prescription?").
Task assignment and tracking that can be used to assign follow-up tasks to specific staff members and track their completion.
Structured note fields for documenting call outcomes, including what was discussed, actions taken, and patient feedback.
Call tracking templates to document key follow-up call elements, such as whether the patient completed recommended actions or needed additional support.
Call logs that maintain records of completed and scheduled follow-up calls, ensuring no patient is missed.
Call outcome tracking to monitor call completion rates, patient satisfaction, and follow-up compliance.
Use this worksheet with the practice to document the resources they will need for the follow-up process and create a plan for engaging them.
Task 6. Create job aids and response protocols for individuals conducting the after-visit process to follow.
Work with the practice to develop protocols for the staff conducting outreach to follow based on common tasks expected as part of the follow-up process.
Depending on the goals and scope of the after-visit follow-up support, these might include protocols that provide guidance to non-clinical staff on:
Care plan adherence 
Medication adherence 
Self-management support and education
Scheduling preventive services 
Coordinating lab testing 
Addressing behavioral and social health needs 
Navigating and completing referrals 
Identifying and escalating urgent issues 
Communicating patient information with the PCP 
Communicating patient concerns/praise regarding visits with the care team
These protocols can be designed job aids for training non-clinical staff and to help them implement and sustain desired follow-up actions by staff once the process is implemented.
Job Aid and Response Protocol for After-Visit Follow-Up Calls for MAs
This job aid and response protocol provides a framework for medical assistants (MAs) to conduct follow-up calls under various circumstances.
Follow-Up Call Steps
Consult the call list provided by the office manager
Review patient information 
Access the patient’s electronic health records (EHRs). 
Confirm the following details: o Reason for the follow up (e.g., medication adjustment, test results, appointment scheduling). 
Primary care professional’s (PCP’s) notes and instructions. 
Any previous documentation related to the visit.
Initial contact 
Attempt to contact the patient by phone or preferred communication method. 
If the patient answers: 
Introduce yourself and the purpose of the call (use script A). 
Verify the patient’s identity (e.g., full name, date of birth). 
If unable to reach the patient: 
Leave a detailed yet HIPAA-compliant (do not disclose personal health information) voicemail that includes your name, the practice’s name, and a callback number.
Actions based on patient’s follow-up needs
(Fill in as appropriate for specific scenarios) 
Escalation Protocol Table
Conclude the call 
Summarize the steps taken during the call. 
Ask if the patient has additional questions or concerns. Remind the patient of the next steps (e.g., appointments, actions they need to take). 
Thank the patient for their time.
Document the call 
Record the following in the EHR under the “Name” tab:
Date and time of the call. o Reason for follow-up and actions taken. 
Patient’s response and any concerns raised. o Escalations to PCP or other team members.
Notes: Ensure HIPAA compliance during all communications.
Use ​this ​worksheet to help the practice create a job aid for the follow-up process they will be implementing or enhancing. If the practice is implementing multiple processes with different workflows, create one for each new workflow or process.
Task 7. Use Plan-Do-Study-Act processes to conduct small tests of the process and refine it before implementing.
Before the practice goes live with the after-visit follow-up process, work with them to test and refine it before implementing.
Use a QI process like Plan-Do-Study-Act (PSDA) cycles to structure the testing process. Have the non-clinical staff conduct calls to three to four patients and provide feedback to the team on the content of the calls, their response, and the effectiveness of the workflow.
Work with the non-clinical staff to make refinements to the process and then test it again until it is ready to implement. Areas for testing include:
Use the Plan-Do-Study-Act worksheet to help the practice plan and document the outcomes of each PDSA cycle or use your own form.
Task 8. Refine job aids and train staff.
Work with the practice to refine the workflows and associated process maps created during Tasks 1–9 and refine them for implementation. Similarly, work with them to update the job aids and response protocols they developed during Task 6 to reflect changes and enhancements made during the PDSA process.
Help them schedule and deliver training to staff on the process using group trainings, as well as “elbow support” and audit and feedback process. You can review the Agency for Healthcare Research and Quality (AHRQ) module on helping practices scale improvements for a quick reminder on elbow support coaching sessions.
Go to the job aids the practice created before the PDSA and make any changes needed based on lessons learned from the PDSA cycles.
Task 9. Implement the process and monitor performance.
Work with the practice to implement the follow-up and reporting processes that help them monitor staff adoption, performance, and outcomes.
Use this template to help them create weekly performance report on after-visit follow-up work to support maintenance of the new process during the early stages.
Task 10. Add the process to the policies and procedures manual, onboarding training, and practice QI program.
A. Create policies and procedures that document the new processes and add them to the practice’s operations manual.
Work with the practice to ensure the new processes are fully incorporated into their policies and procedures (P & P) manual, as well as the new staff training program.
The practice can use the worksheets they completed as part of this Blueprint Guide as an informal P & P document or rewrite them into a formal P & P to include in their Standard Operating Procedures manual.
A formal P & P document might include: 
Goals
Purpose
Target populations
Reminder types, methods, and timing
Methods of delivery
Workflows
Performance metrics
Alignment with HIPAA and any relevant billing regulations
B. Revise Job Descriptions and Staff Evaluation Protocols
Revise job descriptions for positions with significant responsibilities for the after-visit follow-up workflows to include the addition of these tasks and responsibilities, as well as how their performance will be evaluated.
Examples of role updates on job descriptions:
MAs: Conduct phone outreach to patients living with diabetes with A1C over 9 to check on medication adherence and SDOH.
Care coordinators: Conduct follow-up with higher-risk people living with diabetes and with A1Cs equal to or greater than 9 to check on completion of referrals and tests due.
Examples of updates to staff evaluations:
MA: Completed target 10 follow-up calls per week
Care Coordinator: Completed follow-up outreach for referral navigation with at least 80% of patients requiring follow-up
These revisions not only clarify expectations, they ensure accountability, helping the practice build a cohesive approach to follow-up. Incorporate training on after-visit follow up into onboarding training for new hires for the positions that will be responsible for the process.
Use this worksheet to create additions to add to job descriptions and this worksheet to draft additions to staff performance evaluation standards.
C. Add to Practice QI Program:
As with any improvement you are working with a practice to implement (or enhance), select a few key metrics that align with their QI objectives that can be tracked as part of their routine QI activities before you complete your work on after visit follow-up.
These steps will help embed the follow-up activities into daily operations, support staff consistency, and drive measurable improvements in patient care outcomes.
Metrics to consider monitoring might include:
# of patients eligible for after-visit follow up process
# of attempts per patient for follow up process
# status of follow-up effort (received, declined, unable to reach, etc)
Type of support provided
# of patients requiring escalation
Average number of minutes spent per follow-up cycle
Impact on patient satisfaction
Impact on patient care gap closure
Use this worksheet to prepare recommendations to the practice QI team to identify and track performance metrics associated with after-visit follow-up
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