Providing Continous Follow-up Care

How to check in with patients, monitor their progress, and support them between clinic visits.

Understanding Your Role as a Personal Doctor

Being a Personal Doctor on sureCova goes beyond responding when patients send you messages. It involves maintaining an ongoing relationship with your patients, checking on their progress, and helping them manage their health between clinic visits.

For patients living with chronic conditions, consistent follow-up can help you identify new concerns, assess their response to treatment, reinforce adherence to their care plans, and determine when further medical attention may be needed.

As a Personal Doctor, you should take a proactive approach to patient care. Rather than waiting for patients to reach out whenever they have a problem, use the tools available on sureCova to maintain contact, review their progress, and follow up when clinically appropriate.

The aim is to make follow-up care a consistent part of your practice, helping patients feel supported while enabling you to maintain continuity of care beyond the consultation room.

Creating and Managing Patient Check-Ins

Regular check-ins help you stay connected with your patients, understand how they are progressing, and identify concerns that may require further attention.

sureCova provides a Create Check-In tile on the home page, allowing you to schedule check-ins for individual patients and review existing check-ins.

How to Create a Check-In

1. Open your sureCova doctor app.
2. Select the Create Check-In tile on the home page.
3. Select the patient you want to check in with.
4. Configure the check-in questions and schedule it for the appropriate date.

Customising Your Check-In Questions

sureCova provides six customised check-in questions to help you gather information from patients during follow-up. You can edit these questions or add more questions to suit your clinical practice and the needs of individual patients.

When customising your questions, focus on information that helps you assess the patient's progress, identify new concerns, and determine whether further clinical attention is needed. Depending on the patient's condition, you may want to ask about current symptoms, response to treatment, medication adherence, or new health concerns.

Choose questions that are relevant to the patient's condition and care plan. The aim is to make each check-in useful for clinical follow-up.

How Patients Receive and Complete Check-Ins

Once you have scheduled a check-in, the patient receives the questions through their sureCova app on the scheduled date. The patient can respond to the questions directly in the app.

Encourage patients to provide accurate and complete answers so that you can better understand their progress and identify any concerns that may need attention.

Reviewing Patient Responses

You can review patients' responses to their check-ins in the app. Use the information provided to assess their progress, identify changes in their health status, and determine whether further follow-up or clinical intervention is needed.

If a patient's responses raise concerns, initiate a conversation with them to clarify the situation and decide on the appropriate next steps. Where necessary, arrange a consultation, request investigations, adjust the care plan, or recommend an in-person assessment.

Reviewing Existing Check-Ins

You can also review check-ins that have already been created. This helps you keep track of your follow-up activities and maintain continuity in the care you provide.

Remember that check-ins complement clinical consultations; they do not replace a proper assessment when a patient's symptoms or responses indicate that further medical attention is required.

Categorising Patients and Setting Care Goals

Not every patient requires the same level of follow-up. Some patients may need close monitoring, while others may be stable and require less frequent check-ins. sureCova allows you to categorise your patients according to the level of monitoring they require.

You can classify patients into three categories:

• Active: For patients who require close monitoring and more frequent follow-up due to their current health needs.
• Monitoring: For patients whose progress needs to be reviewed regularly, even though they may not require the same level of attention as those in the Active category.
• Stable: For patients whose conditions are stable and who may require less frequent monitoring, depending on their clinical needs.

Use your clinical judgement when assigning or changing a patient's category. A patient's status may change over time, so review their category as their condition, treatment response, and care needs evolve.

Setting Clear Goals for Your Patients

In addition to categorising patients, you can set clear goals to guide their ongoing care.

These goals should reflect the patient's condition, treatment plan, and individual healthcare needs. Depending on the patient, a goal might involve improving medication adherence, attending a scheduled review, monitoring a relevant health measurement, or making an agreed lifestyle change.

Where appropriate, discuss these goals with your patients so they understand what they are working towards and what you expect from them.

Clear goals help patients understand that their care is being actively managed. They also give you and your patients a shared direction for follow-up conversations and future reviews.

Review progress towards these goals during check-ins and consultations, and adjust them when necessary.

Remember: Patient categories and care goals are tools for organising follow-up care, not substitutes for clinical assessment. Always base monitoring decisions on the patient's current condition and individual needs.