What should be assessed during a 1-month follow-up call with a patient?

1-Month Follow-Up Call Assessment

During a 1-month follow-up call with a patient, you should systematically assess treatment response, medication adherence, adverse effects, symptom changes, and need for further intervention, with the specific content tailored to the patient's condition and treatment. 1

Core Assessment Elements Across All Conditions

Treatment Efficacy and Response

• Ask about symptom improvement or worsening since discharge or treatment initiation, as this is the primary indicator of whether the current management plan is working 2, 1
• Evaluate whether the patient has achieved meaningful improvement in their condition-specific symptoms (e.g., pain relief, symptom resolution, functional improvement) 1, 3
• For patients without symptom relief at 1 month, recognize this as a critical decision point - they are unlikely to experience benefit at 6 months, making this an essential juncture for modifying therapy 1

Medication Management

• Verify that the patient obtained their prescribed medications and understands how to take them correctly 4
• Assess medication adherence by asking if they are taking medications exactly as prescribed or feeling the need to take more or take them more frequently 1
• Identify and resolve any medication-related problems, including confusion about dosing, side effects, or drug-drug interactions 4
• Review supply management issues, including pharmacy suitability and home storage 2

Adverse Effects and Safety Concerns

• Screen systematically for common side effects specific to the patient's medications (e.g., constipation, drowsiness, nausea for opioids; gastrointestinal symptoms for metformin) 1, 5
• Identify warning signs of serious complications that require immediate intervention 1
• For patients on high-risk medications, assess for specific toxicities (e.g., lactic acidosis symptoms for metformin patients, hypoglycemia for diabetes medications) 5

Functional Status and Quality of Life

• Assess interference with daily activities using structured approaches - ask specifically about enjoyment of life and general activity levels 1, 3
• Determine progress toward patient-specific functional goals, such as return to work, family responsibilities, or social engagement 1
• Evaluate whether overall well-being and quality of life have improved since starting treatment 1

Condition-Specific Assessment Priorities

For Patients on Chronic Medications (e.g., LTOT, anticoagulants, opioids)

• Confirm that blood gases, flow rates, or laboratory parameters remain therapeutic and that treatment is still indicated 2
• Assess compliance with therapy, as non-adherence is a common cause of treatment failure 2
• Review the patient's understanding of risks and proper use of their therapy 2

For Post-Procedure or Post-Hospitalization Patients

• Identify new medical problems that may require referral back to the inpatient team or specialist 4
• Reinforce discharge instructions, as 42% of patients require further clarification 6
• Assess whether the patient needs direct medical intervention for worsening clinical status 6

For Patients with Self-Limiting Conditions (e.g., BPPV, acute conditions)

• Document whether symptoms have resolved or persist, as this determines need for further treatment 2
• Reassess diagnostic accuracy if symptoms persist, considering alternative diagnoses or superimposed conditions 2
• Evaluate whether patients initially managed with observation now require active intervention 2

Practical Implementation Considerations

Timing and Structure

• The first follow-up should occur no later than 1 month after treatment initiation, though earlier contact (around 1 week) may be appropriate for certain conditions 2, 1
• For faster-onset medications (alpha blockers, beta-3 agonists), follow-up can be as early as 4 weeks; for longer-onset drugs (5-ARIs), waiting 3-6 months is advised 2
• Schedule visits at 2-week to 6-week intervals for patients just starting therapy or requiring treatment escalation 2

Who Should Make the Call

• Calls can be made by physicians, nurses, pharmacists, or social workers, assigned based on the complexity of issues and staff expertise 6, 7
• Nurse-coordinated follow-up is effective and feasible for routine assessments 2
• The average call duration is approximately 70 seconds for straightforward cases 6

Documentation and Communication

• Document all relevant findings, medication changes, and the plan for next follow-up on the patient's anticoagulation card or medical record 2
• Ensure written communication between different healthcare providers about the follow-up plan and execution 2
• Identify patients who require more frequent follow-up based on high-risk features (e.g., depression, substance use history, high-dose medications, concurrent CNS depressants) 1

Red Flags Requiring Immediate Action

• Worsening clinical condition or new concerning symptoms - these patients require direct medical intervention, not just advice 6, 4
• Persistent ulceration, new growths, or hyperkeratosis (for dermatologic conditions) - these require urgent specialist referral to exclude malignancy 2
• Signs of serious medication complications (e.g., lactic acidosis symptoms, severe hypoglycemia, bleeding on anticoagulation) 5
• Non-compliance with critical safety instructions (e.g., smoking while on home oxygen, not using prescribed anticoagulation) 2

Common Pitfalls to Avoid

• Do not assume patients understand their discharge instructions - 42% require further clarification even when they initially seemed to understand 6
• Avoid focusing solely on symptom resolution without assessing functional improvement and quality of life 1, 3
• Do not overlook medication-related problems - pharmacist-led calls identify and resolve issues in 19% of patients 4
• Recognize that very elderly or disabled patients may not be able to apply medications appropriately despite understanding instructions 2