“Promise to Come” Diary: An innovative initiative to increase patient retention through health provider-patient partnership

Written by; Dr Martha Tsere

Background: The scale-up of HIV care and antiretroviral therapy (ART) services in Dara-es-salaam, Tanzania is the  Management and Development for Health (MDH)’s flagship program’s where coverage increased from about 18,050 People living with HIV/AIDS (PLHIV) accessing the services in 2007 to more than 141,919 PLHIVs in 2015. Despite MDH’s tremendous program achievements especially in setting strategic patients tracking systems, there  is a growing concern on poor retention on ART, especially patients missing scheduled appointment visits despite of being tracked.
Infectious Disease Clinic (IDC) is one of the HIV clinics supported by MDH in Ilala district in Dar es salaam. IDC’s data showed that as of August 2013 only 54% of clients that were missing from the clinic were able to return for care after being tracked by the healthcare providers (HCP) through phone calls or home visits. The findings were far below the set objective of returning back 80% of defaulters to continue with their ART by December 2013.

As the number of patients on ART grew it was crucial to develop an innovative initiative to prevent poor compliance to follow up and improve retention to HIV care. This meant coming up with an intervention that was cost effective, user friendly and reliable by improving the mechanism of follow up of clients that responded with ‘promise to come’.

The traditional tracking system at IDC: The system that was being used at the facility to track missing clients was by use of a daily printed list from the data base showing the missing clients. These clients were tracked by HCP initially by telephone call and those with no response or no mobile numbers were tracked by home visits. Responses were marked in counter books of which majority that were contacted responded with ‘promised to come’ on a certain date. The practice was that once these clients gave the promised date, assumption was that they would actually return and hence were not followed up but instead new missed clients were tracked every day from a new printed list. The consequence was that these clients rarely returned on time or at all and hence only worsened the retention status at the facility.

Just as the business marketing strategy states ‘fortune is in follow up’, in this case it was crucial that the clients that promised to come were followed up on the date or a day before the proposed date of attending clinic.

The evolution of the new “Promise-to-come” Initiative: it was proposed that instead of healthcare workers setting an appointment date for clients, the new initiative was to ask clients to mention their convenient date that they promised to return which was recorded in a special register that was named “Promise –to-Come” diary.

The site formed a team to implement the initiative, the team comprised of a data clerk who was responsible for printing out the ‘missed appointment’ list and also updating the database once the client returned to clinic, the tracker was in charge of calling the clients that missed appointment and thereafter noting down their promised date in a diary. The tracker was also in charge of recalling the clients on the day that they promised to come to the clinic. The communication between the tracker and the client needed to emphasize that it was a reminder call for the promised date of return. This was different from past practice where trackers would converse with the clients as if it was the first tracking call, which in most cases led to clients giving a promised to come date during each call thus never returning.

Another strategy that tallied with this system was to inform the client to see the tracker and nurse counselor upon arrival at the clinic and identify themselves as a missing client that returned so as to have their information updated and also to have further adherence counseling.

promise to come

This strategy resulted in a tremendous improvement in the trend of clients that actually return after being tracked and followed up based on their promised to come dates. Before the intervention an average of 54% of clients returned after being tracked but with the new initiative, 86% of clients were able to return during the month of December 2013.  Evidently, more clients that were followed up using the promised to come strategy returned as compared to those that were only tracked once. This intervention had such an effect to a point that clients dreaded missing their appointments as they believed that they will be tracked down like a ‘’vulture hunting its prey ‘’as one client put it.

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The trackers admitted that the system was so smooth such that it much easier for any health care worker (nurse counselor or clinician) to track the clients and bring back clients that are reachable rather than those not reachable via telephone or those with wrong map cue. Another lesson learnt through communication and counseling of clients that have a habit of missing their clinic appointment was to have an agreement with the clients on the appointment dates.

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This system proved so much success that it was inevitable not to roll it out to other facilities within the district and eventually the whole region is now making use of this practice in partnership with the ministry system of tracking and appointment registers. It is an affordable system that is efficient and can me practiced by any health facility and health care provider hence proving its sustainability.

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