How to Create a Follow-Up and Handover System for Mission Patients

You are standing in a crowded church-turned-clinic on the last day of a one-week mission. You just saw a 52-year-old woman with new-onset diabetes and blood pressures in the 180s. You gave meds, did some brief counseling, wrote everything down on a paper chart…and tomorrow you fly home.

You know exactly what is bothering you on the drive back to the guesthouse: “What happens to her now?”

That feeling? That is your conscience trying to do quality improvement. Let’s build you a system so you never have to wonder “what happens now?” without having a concrete answer.

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Step 1: Decide What You Are Actually Responsible For

Before you build any follow-up or handover system, you need a clear ethical stance. Otherwise you will design a feel-good process that does nothing.

Here is the line I draw, and I think it is the only defensible one:

If you start care, you own reasonable follow-up and safe handover.

Not infinite follow-up. Not “forever responsibility.” Reasonable follow-up and safe handover, defined clearly.

Concretely, that usually means:

• You are responsible for:

  • Communicating a clear plan to the patient and local system
  • Ensuring time-sensitive items (results, referrals, med changes) will be acted on
  • Not initiating therapies you know cannot be monitored at all
  • Documenting in a way that local clinicians can actually use

• You are not responsible for:

  • Guaranteeing outcomes
  • Building an entire health system from scratch during a 10‑day trip
  • Personally calling every patient for years

You need this clarity because it drives design decisions:

• Will you use paper only, or a simple spreadsheet, or a shared EMR?
• Do you need a local nurse champion, or a full “continuity clinic” structure?
• Do you limit the complexity of new diagnoses you make?

Make this explicit with your team before the trip, not during the final debrief when everyone is tired and emotional.

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Step 2: Map the Life Cycle of a Mission Patient

You cannot fix follow-up if you do not understand the full path of the patient’s contact with your project.

Use a simple flow like this.

Mission Handover Workflow

Step	Description
Step 1	Team planning
Step 2	Define guardrails and tiers
Step 3	Create templates and logs
Step 4	Clinical care during mission
Step 5	Identify follow-up patients
Step 6	Fill handover sheets and log
Step 7	End-of-mission handover meeting
Step 8	Local follow-up actions
Step 9	Post-mission check-in
Step 10	Adjust system for next mission

Your job is to make sure points F, G, H, I exist in reality, not just on the whiteboard.

So walk through these questions with your host partner:

• Where are patients currently recorded? A ledger? Excel? WhatsApp? Nothing?
• Who, on the local side, “owns” chronic patients now, if anyone?
• What are realistic follow-up options:
  • Local clinic visit?
  • Community health worker home visits?
  • Phone / SMS / WhatsApp check-in?
  • Next mission team, six months later? (Often a terrible plan by itself.)

You are going to plug your system into their reality, not the system you wish they had.

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Step 3: Build a Simple, Ruthless Patient Tracking System

This is the backbone. If you cannot generate a list of “patients we still owe something to,” you do not have a system. You have vibes.

You want two things:

1. A master log of all patients seen
2. A focused follow-up list of patients with open tasks

Keep it brutally simple.

3.1 Core data you must capture

At minimum, your follow-up list needs:

• Patient identifier
• Contact details / locator info
• Diagnosis category
• What needs to be done
• By when
• Who is responsible

Turn this into a structure the team can actually use:

Field	Purpose
Patient ID / Name	Unique identification
Age / Sex	Basic clinical context
Contact / Locator	How to find them again
Key Diagnosis	Main problem needing follow-up
Action Needed	Specific next step
Due Date	When it should happen
Assigned To	Local person or clinic

I have seen groups try to build EMR-level forms on day one and then abandon them by day three. Do not do that. A clipboard with this table printed in bulk is infinitely better than a half-built app nobody maintains.

3.2 One-page “handover summary” per patient

For any patient who needs follow-up (not every single URI), create a one-page handover sheet. Paper is fine. The rule: a local clinician should be able to understand the case in under 30 seconds.

Essential sections:

• Patient details (ID, age, sex, contact)
• Problem list (3–5 bullet points, max)
• Medications started/changed (with doses in local units, not just mg if that confuses staff)
• What we did during mission (tests, key findings)
• Precise follow-up plan:
  • What needs to happen
  • When
  • Where
  • By whom
• Red-flag instructions for the patient (in their language)

Make this a template and print a stack. Teach every clinician on the team to fill it out for:

• New chronic diagnoses (diabetes, HTN, seizure disorder, HIV)
• Any new high-risk med (anticoagulants, insulin, TB regimen)
• Any abnormal test pending further evaluation (suspicious mass, positive screen)
• Any serious acute condition that is not fully resolved but stable enough to go home

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Step 4: Define Follow-Up Categories and Timeframes

Not all follow-up is created equal. You need triage categories, or your local partner will drown in a sea of “maybe follow up in 3–6 months” noise.

Split your follow-ups into three tiers:

Tier 1: Critical / High-Risk (non-negotiable follow-up)

Examples:

• New insulin start
• Newly recognized advanced heart failure
• Suspected malignancy
• Positive TB screen or new TB treatment start
• Untreated BP > 180/110 with end-organ risks

Plan:

• Follow-up within 3–7 days, or at most 2 weeks
• Confirm during the visit how follow-up will happen:
  • Specific appointment date at local clinic
  • Community health worker visit booked
  • Phone call scheduled (with who, at what time)

Tier 2: Moderate Risk / Chronic Disease Adjustment

Examples:

• New diagnosis of hypertension managed with oral meds
• New diabetes on orals only
• Asthma that needed step-up therapy
• Epilepsy with medication titration

Plan:

• Follow-up within 4–8 weeks
• Clear instructions for:
  • Where to refill meds
  • What to monitor (BP log, blood sugars, seizure frequency)
  • When to escalate back to a clinician

Tier 3: Routine / Opportunistic Follow-Up

Examples:

• Stable chronic patients whose meds you refilled
• Mild depression with counseling and resource referral
• Non-urgent surgical referrals

Plan:

• Follow-up “when next attending clinic is convenient”
• Educate patient to seek care if symptom X or Y occurs
• Hand over to system, but do not clog the high-risk list

Put this on paper and on the wall in the clinician area so everyone is sorting into the same buckets.

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Step 5: Choose and Empower Local Owners

If nobody local owns follow-up, you have nothing. The worst pattern I see is “we’ll email them a list later.”

No. Name names.

You need at least two local roles:

1. Clinical Owner
   Usually:

   • The medical director of the local clinic/hospital, or
   • A senior nurse or clinical officer

   Responsibilities:

   • Receives the follow-up list
   • Reviews and prioritizes high-risk cases
   • Allocates them to providers / community health workers
   • Flags cases they cannot handle (for referral planning)

2. Data / Coordination Owner
   May be:

   • A clinic receptionist
   • A records clerk
   • A community health worker with literacy and reliability

   Responsibilities:

   • Maintains the follow-up log
   • Checks off completed tasks
   • Tracks no-shows
   • Communicates with your team after the mission (if agreed)

You need to sit down, in person, with these people and:

• Show them the log and handover sheets
• Walk through 3–5 example cases
• Ask them to explain back the system in their own words
• Adjust for their reality (e.g., if they say “we never call patients, nobody answers phones,” then stop building a call-based plan)

This conversation is not optional. It is the system.

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Step 6: Design Reliable Communication Channels

A good follow-up system dies on the hill of “I sent you an email, did you not get it?”

You need to standardize how communication happens between:

• Mission team → local partner
• Local partner → patients
• Local partner → next mission team (if recurrent trips)

6.1 For mission team → local partner

Pick one primary and one backup channel. Examples:

• Primary: Shared Google Sheet (if reliable internet)
• Backup: Printed and signed follow-up list physically handed over

or

• Primary: Encrypted WhatsApp group with PDF and photos of the lists
• Backup: USB stick + printed documents left at clinic

Just do not design a system that depends on:

• Your personal laptop
• A single volunteer’s private email
• A “smart” EMR nobody else knows how to log into

6.2 For local partner → patients

Clarify their existing practice:

• Do they ever call patients? Or only community visits?
• Do they send SMS reminders?
• Is there a market-day clinic pattern they can leverage?

Then make the follow-up plan match that pattern. Not your fantasy of what follow-up should look like.

Example options:

• Appointment card with:
  • Date, time, place
  • Purpose (“BP check,” “sugar test,” “wound review”)
• SMS template they can send to all Tier 1 patients
• A list of Tier 1 patients given to community health workers for home visits

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Step 7: Create a Handover Ritual at the End of Every Mission

The last day is usually chaos: packing meds, rushing to the airport, last-minute goodbyes.

You need to carve out protected time for handover. Treat it like a formal sign-out in an ICU. Because ethically, that is what it is.

Minimum agenda (60–90 minutes):

1. Review the follow-up list case-by-case with the local clinical owner
   • Highlight Tier 1 first
   • Confirm plan for each:
     • Where they will be seen
     • By whom
     • Rough date / timeframe
2. Hand over physical documents
   • Patient handover sheets (organized by risk tier or alphabetically)
   • Master follow-up log
3. Confirm how and when you will check in
   • One check-in at 1–3 months
   • One person on each side designated as contact
4. Document the meeting
   • Simple one-page summary:
     • Number of patients requiring follow-up by tier
     • Agreed next steps
     • Barriers flagged (e.g., “we cannot manage insulin dose titration safely here”)

Do not skip this. I do not care how late your flight is. If you cannot do this, you did not design the mission schedule properly.

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Step 8: Put Guardrails on What Care You Start

A lot of follow-up problems are created upstream. If you start interventions that the local system cannot sustain or monitor, you are generating harm and future guilt.

You need a treatment eligibility filter based on local capacity. Decide it with the host partner before clinic opens.

Example Risk of Treatment vs Local Capacity

Category	Value
Simple BP meds	2
Oral diabetes meds	3
Insulin therapy	7
Warfarin anticoagulation	8
New chemo regimen	10

Think in terms of:

• Monitoring needs (labs, INR, glucose)
• Side effect risks
• Requirements for emergency management (hypoglycemia, bleeding)
• Availability of follow-up meds locally

Rules of thumb that have saved more than one mission:

• Do not start warfarin if INR testing is nonexistent and no clinician understands dosing.
• Do not start insulin without:
  • Reliable access to insulin
  • Patient or family education on dosing and hypoglycemia
  • Some mechanism for dose adjustment
• For conditions like new HIV, TB, or cancer:
  • Prioritize linkage to an existing program rather than playing “mini-oncologist” for a week

Put your “we do not start this here” list on paper. Share it with every clinician on the team.

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Step 9: Build a Micro Quality Loop After the Mission

A system without feedback decays. You need a small, realistic loop where you learn what actually happened.

No 50-page report. Just a simple check-in.

Within 1–3 months after the mission, you or a designated team member should:

• Contact the local data / coordination owner
• Ask for:
  • Number of Tier 1 patients who:
    • Were seen
    • Were not reached
  • Major problems encountered (patients could not afford meds, clinic closed, etc.)
• Update your follow-up log with:
  • Completed
  • Lost to follow-up
  • Deceased (if known)

Use this to adjust:

• Your follow-up categories (were too many in Tier 1?)
• Your treatment choices (did you start therapies they could not sustain?)
• Your handover clarity (were local staff confused about plans?)

Over 2–3 missions, you can refine this into something shockingly robust, if you are willing to listen to the uncomfortable parts.

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Step 10: Address the Ethical Tension Head-On

If you are doing this right, you will run into hard cases.

Example: You diagnose advanced cervical cancer in a setting where there is no oncologist within 300 km and the patient cannot afford travel.

Here is the ethical sequence I recommend:

1. Be honest with patient and family
   In language they understand:

   • What you know
   • What you do not know
   • What treatment options exist (if any) and where

2. Engage the local clinician in the conversation
   They will still be here when you leave. They know:

   • Referral possibilities
   • Cultural norms around bad news
   • Realistic palliative options

3. Set a follow-up goal that fits reality
   Maybe:

   • Referral visit arranged
   • Palliative care and symptom control only
   • Family meeting with local pastor / community elder

4. Document your reasoning
   On the handover form:

   • Why certain treatments were not started
   • What was offered
   • Patient preferences (if stated)

You cannot fix structural injustice on a 10‑day trip. You can refuse to add ethical sloppiness to it by pretending “we will follow up” when you know you will not.

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Practical Tools You Can Implement This Week

Here is a compact toolkit you can build now and bring to your next mission.

1. Master follow-up log template (1–2 pages)
   • As in the table above
2. One-page handover sheet template
   • Patient details
   • Problem list
   • Meds
   • Investigations
   • Follow-up plan
   • Patient instructions
3. Risk tier cheat sheet
   • Examples of Tier 1 / 2 / 3 with timeframes
4. End-of-mission handover checklist
   • Review list with local clinician
   • Hand over documents
   • Confirm communication channels
   • Schedule 1–3 month check-in
5. Treatment guardrail list
   • “We will not start” meds and interventions in this context
   • Agreed with host partners

Laminate the critical pages. Put them in the clinician area. Make them part of the orientation talk on day one.

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Example: Putting It All Together for a Single Patient

Let us run your 52-year-old woman with new diabetes and severe hypertension through this system.

1. During the visit

   • Diagnose DM2 and HTN
   • Start oral hypoglycemic (available locally) and two BP meds they routinely stock
   • Provide brief diet and medication education in her language through interpreter

2. Risk tiering

   • New DM and severe HTN → Tier 1 (critical) for first follow-up

3. Handover sheet

   • Fill out one-page summary:
     • Diagnosis: DM2, HTN
     • Meds and doses using local names
     • Baseline BP and glucose values
     • Red flags for patient: severe headache, chest pain, confusion, very low sugar symptoms
     • Plan: follow-up BP and glucose check at local clinic in 7 days

4. Clinic linkage

   • While patient is still present, receptionist gives:
     • Specific appointment date and time at local clinic
     • Paper appointment card

5. Follow-up log entry

   • Add her to master follow-up log:
     • Name/ID, contact, diagnosis, action (“clinic visit in 7 days”), due date, assigned to “Nurse Samuel – hypertension/diabetes clinic”

6. End-of-mission handover

   • Review her case with local clinical owner:
     • Confirm she is on local formulary meds
     • Confirm nurse Samuel runs that clinic and will be working next week

7. Post-mission check-in (1–3 months)

   • Ask local data owner:
     • Did she attend?
     • Any major issues?

If she never shows, that is still information. On your next mission, you might:

• Add home visits for Tier 1 patients
• Adjust how you explain the seriousness of the condition
• Work with local staff on retention strategies

The point: you had a system. You did not just hope.

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Common Pitfalls and How to Avoid Them

Frequency of Follow-Up System Failures on Missions

Category	Value
No clear owner	80
Over-complex tech	60
No risk tiering	55
Unrealistic therapies	50
No end handover	70

Some failures I see repeatedly:

1. No single person is responsible
   Fix: Name the local clinical and data owners. In writing.

2. Overly complex digital solutions
   Fix: Start with paper. If the local partner begs you for an app and has used one before, reconsider. Otherwise, paper.

3. Everything is “follow-up if possible”
   Fix: Use tiers. Protect Tier 1 with obsession. Let Tier 3 be opportunistic.

4. Starting high-risk regimens in low-capacity settings
   Fix: Agree up front what you will not start. Stick to it even when you are tempted.

5. No protected time for handover
   Fix: Schedule the handover meeting in the mission agenda from day one. Non-negotiable.

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Visual: High-Level Handover Workflow

Mission Handover Workflow

Step	Description
Step 1	Team planning
Step 2	Define guardrails and tiers
Step 3	Create templates and logs
Step 4	Clinical care during mission
Step 5	Identify follow-up patients
Step 6	Fill handover sheets and log
Step 7	End-of-mission handover meeting
Step 8	Local follow-up actions
Step 9	Post-mission check-in
Step 10	Adjust system for next mission

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FAQ (Exactly 3 Questions)

1. What if there is truly no local clinic or provider to hand over to?

Then you either:

• Limit what you do to:
  • Acute, self-limited care
  • Health education
  • Support of existing community structures (CHWs, churches, NGOs)
• Or you commit to building that follow-up capacity with the host (not in a week, but as a multi-year partnership).

Providing complex, ongoing treatments with zero local handover option is unethical. If a setting has no follow-up capacity at all, your mission should focus on capacity-building, not chronic disease management.

2. How do we handle language barriers in follow-up instructions?

Design your materials with the local partner:

• Use bilingual forms: English (or your team language) + local language
• Use pictograms for key instructions (med timing, danger signs)
• Train interpreters to deliver a standard script for:
  • Follow-up explanation
  • Red flags
  • Where to go if things get worse

Always test the instructions with a local staff member first: “If you only had this paper, would you know what to do?”

3. How much follow-up is “enough” to be ethical?

You aim for reasonable continuity, not perfection. For high-risk patients, I expect at least:

• A documented follow-up plan agreed with local staff
• A realistic timeframe
• A local clinician who knows they own the next step

If you consistently cannot meet that bar for most high-risk patients, your mission model is broken. You either fix the system (partnership, capacity, schedule) or you stop offering services that require follow-up.

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Open your last mission’s records right now—digital or paper. Can you produce a list of patients for whom your team still owed something at the time you left? If the answer is no, your first step today is to build the follow-up log template described above and commit to using it on your next trip.