April 16, 2025 – Primary care teams can improve patient engagement and long-term health outcomes with more regular (TR) follow-up visits for patients with chronic health conditions, according to a new Hebrew University of Jerusalem study.

Published in the Annals of Family Medicine, the research identifies strategies that foster effective teamwork and proactive care delivery, emphasizing the potential to improve patient outcomes. The research was conducted in collaboration with Leumit Healthcare Services and the Leumit Research Institute.

By comparing clinics that achieve more- and less-regular follow-up visit patterns for such patients, the research highlights the importance of teamwork, flat relational dynamics, and proactive systems such as patient outreach and social worker involvement in achieving more regular care patterns for patients with chronic conditions. The findings suggest that fostering collaboration and adaptability among staff can significantly improve patient engagement and long-term health outcomes.

The study involved semi-structured interviews with 46 healthcare professionals, including physicians, nurses, administrative staff, and pharmacists, from primary care clinics in Israel. Half of the clinics were identified as high-TR, where patients maintained regular follow-ups, and the other half were low-TR. By analyzing their findings, the researchers uncovered several key factors that contribute to the success of high-TR clinics.

Among the most effective strategies were having structured systems in place to encourage follow-up, beginning with administrative staff reaching out to patients and extending to involving family members in care. Clinics with regular follow-up visits also emphasized teamwork and flat relationships between staff, rather than rigid hierarchies. Regular staff meetings, adaptive workflows, informal communication channels with patients, and coordination with social workers also played a critical role in ensuring continuity of care.

“The findings highlight the importance of multidisciplinary collaboration in primary care settings,” says Prof. Adam Rose from the Hebrew University Braun School of Public Health and Community Medicine, Faculty of Medicine. “By fostering a culture of teamwork and adaptability, we can significantly improve the long-term health outcomes for patients with chronic conditions.”

The research paper titled “Primary clinics achieving more regular follow-up of patients with chronic conditions: Contribution of structural, teamwork, and communication aspects among healthcare staff” is now available in Annals of Family Medicine and can be accessed here.

DOI 10.1370/afm.240176

Researchers:
Maram Khazen1, Ligat Shalev1, Avivit Golan-Cohen2, Eugene Merzon2,4, Ariel Israel2,3, Shlomo Vinker2,3, Adam J Rose1

Institutions:
1)    Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem
2)    Leumit Health Services, Research Institute
3)    School of Medicine
4)    Adelson School of Medicine, Ariel University