Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative.

PURPOSE: The purpose of this article is to identify approaches to providing ongoing follow-up and support for diabetes self-management based on the experience of 14 self-management projects of the Diabetes Initiative of the Robert Wood Johnson Foundation. METHODS: This study is a collaboration with grantees of the Diabetes Initiative of the Robert Wood Johnson Foundation, a program focused on diabetes self-management in primary care and community settings. Grantees and national program staff identified key functions that ongoing follow-up and support need to fill and key features of programs that do so. RESULTS: Key functions of ongoing follow-up and support include monitoring of status and self-management, encouragement and facilitation of regular clinical care, encouragement and motivation of self-management, and facilitating skills for coping with changes in circumstances or emergent problems. Key features of ongoing follow-up and support to fill these functions are being available on demand; being proactive in maintaining contact and preventing individuals from "falling between the cracks"; having personal, motivational, and consistent key messages; not being limited to diabetes; and being inclusive of a wide range of resources and settings. CONCLUSIONS: Initial characterization of key features of ongoing follow-up and support has been accomplished. This should facilitate research to clarify how it may best be provided and systematic approaches to doing so. These should lead to health service and policy initiatives supporting this critical dimension of programs to promote self-management and lifelong healthy living patterns.