This process ensures patients are consistently followed up with to maintain continuity of care, improve retention, and close care gaps such as labs, imaging, and follow-ups. Proper outreach helps prevent delays in care and supports better patient outcomes. If the Patient already has a follow up you do not need to worry about this. 

 

📚 Resources Needed

 

🚀 Tips & Tricks

  • Always follow the dot system first — this determines your outreach method.
  • Most patients respond to text before calls, so texting should always come before calling.
  • Use the patient app as your first step whenever possible to keep communication centralized.
  • Document every attempt — if it’s not documented, it didn’t happen.

📘 Instructions

Be sure to follow the steps listed below.

 

Patient Identification & Frequency

Patient lists should be reviewed weekly.

Outreach should follow these timing guidelines:

  • Annual Check-Up → Reach out at 10–11 months since last visit
  • Medication Refill → 7–10 days before medication runs out
  • Labs / Imaging → 3–5 days after order placed
  • Missed Appointment → Within 24 hours
  • One-Time Visit Follow-Up → 30 days after visit


Step 1: Determine Outreach Method (Dot System)

Before contacting the patient, check their status:

  • Purple Dot or No Dot → Send message through Patient App FIRST
  • Orange Dot → Send Text Message FIRST

⚠️ This step is required before any call attempts.


Step 2: Initial Outreach

Based on dot status:

If Purple Dot / No Dot:

  • Send message in Patient App
  • If no response, send text

If Orange Dot:

  • Send text message

Do NOT call yet.


Step 3: Second Attempt (2–3 Days Later)

If no response:

  • Send follow-up text message
  • Then place a phone call
  • Leave voicemail if no answer


Step 4: Final Attempt (14 Days Later)

If still no response:

  • Send final text or app message
  • Attempt final call if needed

If no response after this step:
Mark patient as “Unable to Reach”


Outreach Reasons

Contact patients for the following:

  • Annual check-up scheduling
  • Medication refills
  • Outstanding labs or imaging
  • Follow-up after visit
  • Missed appointments


Message Guidelines

Keep communication clear and simple.


Chat Examples

Annual Check-Up:
“Hi [Name] 👋 You are due for your annual visit. Would you like help scheduling? Remember, we’re always here to help you through your healthcare journey. :)”

Medication Refill:
“Hi [Name] 👋It’s the besa Health team here. We see you may be due for a refill. Let us know if you need help. Remember, we’re always here to help you through your healthcare journey. :)”

Labs / Imaging:
“Hi [Name], you have pending labs/imaging. Please complete them soon and if you need any help, we’re always here for you. :)”


SMS Examples:

Annual Check-Up:
“Hi [Name] 👋 It’s the besa Health team here. You are due for your annual visit. Would you like help scheduling? You can always chat with us through the Patient app for more secure messaging”

Medication Refill:
“Hi [Name] 👋It’s the besa Health team here. We see you may be due for a refill. Let us know if you need help. You can always chat with us through the Patient app for more secure messaging”

Labs / Imaging:
“Hi [Name], you have pending labs/imaging. Please complete them soon. Need help? You can always chat with us through the Patient app for more secure messaging”


Call Scripts (Use When Calling Patients)

When calling, always be clear, simple, and helpful.

Annual Check-Up:

“Hi, is this [Patient Name]?
This is [Your Name] from besa Health. We sent you a quick message earlier and just wanted to follow up.

I’m reaching out because you’re due for your annual visit—we like to stay ahead and keep everything on track.

I can help you get that scheduled now, what does your availability look like?”

Medication Refill:

“Hi, is this [Patient Name]?
This is [Your Name] from besa Health. We sent you a quick message earlier and just wanted to follow up.

I’m calling because it looks like you may be running low on your medication, and we want to make sure there’s no interruption.

Do you need help with a refill or setting up a follow-up?”

⚠️ If patient is out of medication → escalate immediately and get the soonest appointment booked

Labs / Imaging:

“Hi, is this [Patient Name]?
This is [Your Name] from besa Health. We sent you a quick message earlier and just wanted to follow up.

I’m calling because your provider ordered labs/imaging that haven’t been completed yet.

Do you need help scheduling or finding a location?”


Voicemail Script

“Hi [Patient Name], this is [Your Name] from besa Health.
We’re following up regarding your care.

Please give us a call back at (949) 694-3343, or respond to the message we sent you. Thank you.”


Documentation Requirements

Every outreach attempt must be documented in besa EHR:

  • Date and time
  • Method (App, Text, Call)
  • Outcome (Reached / No Response / Voicemail)
  • Patient response
  • If you need to send something such as the lab order form, do it. 
  • Get the appointment booked

⚠️ Missing documentation can impact patient care and reporting.


Escalation

Escalate to provider or clinical team if:

  • Patient reports worsening symptoms
  • Medication has already run out
  • Critical labs are overdue
  • Patient is confused about care plan


Final Check

Before completing outreach, confirm:

  • Correct outreach method was used based on dot
  • Proper follow-up timing was followed
  • All attempts are documented
  • Appointment has been added to the system

Done!