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Play 8: Follow Up

Follow Up


Following up on screening result, brief intervention conversation, or referral to further evaluation and treatment is crucial to on-going, whole health management with each patient.

Purpose of Play 8 To determine which patients will be followed up, how, by whom and in what time frame.
Definitions In the context of S·BI·RT, “Follow Up” refers to any contact with a patient that closes the loop with the primary care practice. It is appropriate for any patient who has a positive screen – whether that patient receives a BI or is referred to specialty services/treatment. It may involve proactive outreach rather than waiting to receive a formal report, and is built into a system. In the case of follow up, a BI means checking back in with a patient who has been identified as needing an intervention; in the case of referral, it may mean checking in with the patient, or checking in with the person or organization to which the patient was referred. It may mean a phone call (e.g., “were you able to make the appointment with XX?”), or some more action(e.g., a follow up appointment). It may be done by the provider, a care coordinator, educator, or other staff, depending upon the staffing and workflow within a specific practice site.
Team members Include EHR/IT personnel.
Measure(s) A target measure for percentage of patients identified for follow up who receive
follow up within an established timeframe.


Recommended Approach

  • Discuss which patients need to be followed up, for what, and by whom.
  • Discuss how you will know that the patient had a positive screen and that you want to follow up at your next encounter. How will it be indicated in the EHR – in a form or in notes? How will the follow up be facilitated by information from the brief intervention conversation or information received back from the referral source? Screens shots of NH S·BI·RT Initiative EHRs are available in Appendix Q.
  • Ensure that internal and external behavioral health referrals can be tracked in your system. How will you know that the referral has been successful?

Keep In Mind

  • Follow up is essential to your relationship with your patient and your establishment of alcohol and drug use information as a meaningful part of your healthcare relationship.
  • Confidentiality of your brief intervention conversation with young patients may make scheduling face-to-face follow up more complex – how will you code the reason for a follow-up visit and explain it to the parent of the youth?
  • Follow up by telephone or text communication, with signed informed consent, by behavioral health or case management staff may be an option at your site.

Corresponding Appendix Section(s)

Appendix Q – Screen Shots of NH S•BI•RT Initiative EHRs

» Continue to PLAY 9: Flow