As noted above, diabetes clients have certain tests that should be done at regular time periods. For example, A1C (the three-month blood sugar average) should be done about every 3 months.
CHWs keep track of all their clients that are due for a physician visit or particular test and make sure that they get the tests or visits that they need.
Process for Recalling Labwork
1. Print off the recall list from the client registry regularly (e.g. every 1-2 weeks). Identify clients who are overdue for A1C, LDL, or ACR, or a regular follow-up visit.
2. Check with the nurses to find out if there are days or times over the next two weeks when clients should not come in (e.g. for blood work).
3. Call each client on the current recall list who is overdue and arrange for him/her to come in. If the client needs LDL, make sure he/she is fasting beforehand.
Hello, _____, this is ________ calling. I’m the diabetes community health worker at the clinic. I’m calling because we’d like you to [select best response(s)]:
Come to the clinic for a follow-up visit with your doctor. It’s been X months since your last visit and you’re overdue.
Come to the clinic to get some blood work done because you’re overdue. We’d then like to schedule a visit with the doctor a week later so he/she can go over the results with you.
[the above response, plus] one of your tests is for cholesterol. You need to have nothing to eat or drink except water or plain tea with no milk or sugar, about 10 to 14 hours before.
Would you like to come to the clinic, or would you rather that I came to your house instead?
Will you need any help to get to your appointment? Do you need a driver? Childcare? An escort?
1. Print off the latest recall list from the Registry at the start of each week.
2. Check with nurses about available days & times over the next four weeks for client appointments. Also, find out when the doctor is available for physician visits.
3. Decide who will be responsible for contacting the client – the CHW or RN. If CHW, then track down the client by whatever means necessary (phone call, send Facebook message, drop by home or wherever else the client likes to hang out, or contact a friend/family who may know how to reach him/her) and ask client to come in at the times suggested by the nurse.
4. Make a note on the recall list of the appointment dates and times for each client. Make a note of which clients could not be contacted or who refused to come.
5. Review this list at the end of the week with the nurse so she/he is aware of who is coming in.
6. When you check the recall list the following week, also look at the notes from the recall lists of previous weeks so that you do not accidentally call back someone who was already contacted last week and who agreed to come in later. (This is important, because some clients may have made an appointment, but they are still on the computer’s recall list because the appointment hasn’t taken place yet.)
Download or use this online CHW sample form to practice the contents of this module.
Please note that these training modules are to be used for the purposes of CHW training in diabetes management. CHWConnect does not provide medical advice or specific diagnostic or treatment information.