Foot Care Nurse Course
Module 7: Patient Education & Follow-Up Care

Lesson 3: Building a Follow-Up Care Plan

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Module 8 · Lesson 3 — Building a Follow-Up Care Plan
Module 8 of 10 · Lesson 3 of 4
Module 8 · Lesson 3

Building a Follow-Up Care Plan

Estimated time: 22 min Longitudinal Care Structure
Learning Objectives

By the end of this lesson, the learner will be able to:

  1. Set risk-stratified visit intervals using the IWGDF framework rather than a single one-size-fits-all schedule.
  2. Construct a six-element written follow-up plan that travels with the patient.
  3. Establish between-visit communication pathways: scheduled, urgent, emergency, and handoff.
  4. Coordinate transitions of care across PCP, podiatry, vascular, wound care, and pedorthist.
  5. Recognize the triggers that should cause you to revise an existing care plan rather than continue it unchanged.

Foot care is a longitudinal relationship, not a one-time visit. The plan you build at the end of every visit determines whether the patient continues to do well, deteriorates between visits without anyone noticing, or has a crisis they don't know how to handle. This lesson covers the architecture of that ongoing relationship: how often to see different patients, what the plan should contain, how patients reach you between visits, and how you coordinate with the rest of the care team.

Why the Follow-Up Plan Matters

What good follow-up structure achieves
Right cadence Visit frequency matched to risk catches problems early without over-treating low-risk patients. A single "every 6–8 weeks" rule serves no one well.
Between-visit safety Most foot complications develop between visits. A clear pathway for reaching you (and clear criteria for when to do so) closes the gap.
Continuity Patients see PCPs, specialists, hospital teams, and home care nurses — often without coordination. Foot care nurses with structured handoffs prevent the dropped balls.

Risk-Stratified Visit Intervals: The IWGDF Framework

Module 5 Lesson 1 introduced the IWGDF risk categories; Module 7 reinforced them in the assessment workflow. This is the consolidated reference for setting visit frequency. The screening interval (full risk re-assessment) is distinct from the foot care interval (routine nail/skin care) — both matter, and they're not the same.

IWGDF risk-stratified follow-up — consolidated reference
Risk 0
Very low risk No loss of protective sensation (LOPS); no peripheral arterial disease (PAD).
Screening Annual foot exam
Routine foot care As patient prefers; no required schedule
Risk 1
Low risk LOPS or PAD alone (one risk factor present).
Screening Every 6–12 months
Routine foot care Approximately every 8–10 weeks if needed
Risk 2
Moderate risk LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity (two risk factors).
Screening Every 3–6 months
Routine foot care Approximately every 6–8 weeks
Risk 3
High risk LOPS or PAD plus history of foot ulcer, lower-extremity amputation, or end-stage renal disease.
Screening Every 1–3 months
Routine foot care Often podiatry-led; nursing role is inspection, education, coordination
Screening interval ≠ foot-care interval

The IWGDF screening interval is for full risk re-assessment (sensory, vascular, deformity, history) — done by a clinician trained in the comprehensive foot exam. The foot-care interval is for routine nail and skin maintenance. A Risk 1 patient might be screened by their PCP twice a year and seen for foot care every 8–10 weeks by you. These are coordinated, not competing schedules. Your note communicates findings back to the screening clinician.

Non-diabetic patients still need stratification

The IWGDF framework was developed for diabetes, but the underlying principle — visit frequency matched to risk profile — applies to other populations. Older adults with arthritis and limited self-care capacity, patients on chronic anticoagulation, post-vascular-surgery patients, patients with chronic edema or recurrent fungal infections all benefit from intervals shorter than annual but longer than monthly. Use clinical judgment when IWGDF doesn't formally apply, and document the reasoning.

The Six-Element Written Follow-Up Plan

Every visit ends with a written plan the patient takes home and a copy that goes in the chart. The plan has six elements — what's been done, what the patient does next, when they come back, when they call sooner, who else is involved, and what would change all of it.

Follow-up plan template — six required elements
Apply at the end of every visit · written copy to patient · documented copy to chart
Element 1
Summary of today's findings
In plain language — what you saw, what you did, what's stable, what's new. Two or three sentences. Patient should be able to repeat this back (teach-back).
Element 2
What the patient does at home
Specific, concrete daily routine: inspection, moisturizer, footwear changes, sock practices. Ideally 2–3 priorities per visit (avoid the information dump from Lesson 1). Pair with written reinforcement.
Element 3
Next visit interval and reason
Risk-stratified per IWGDF (or clinical judgment for non-diabetic patients). Include the reason: "every 6 weeks because you're at higher risk for ulcer recurrence" lands differently than "see you in 6 weeks."
Element 4
When to call sooner — the tiered framework
Apply the Module 6 framework: self-care for routine, call within 24–48 hours for concerning, urgent/emergency for spreading infection or systemic symptoms. Patient leaves with the contact number, hours, and after-hours pathway in writing.
Element 5
Coordination with the care team
Who else needs to know what. PCP gets a note copy as a default. Podiatry, vascular, wound care, pedorthist, PT, diabetes care team — referrals or update notes as appropriate.
Element 6
What would change the plan
Plan-revision triggers: events or findings that should bring the patient back sooner or change the approach. New diagnosis, new medication with bleeding risk, hospitalization, change in mobility or self-care capacity, ulcer development. (See the trigger list below.)

Between-Visit Communication Pathways

The patient needs to know exactly how to reach you, on what timeline, and through which channel for which kind of issue. Ambiguity here is one of the most common failure points in foot care — patients with concerning findings sit on them because they don't know what counts as worth calling about.

Scheduled Next visit per the plan
Routine follow-up at the IWGDF-stratified interval. Most patients fall into this pathway.
  • Reminder system (text, email, or phone call) 1–2 weeks before
  • Reschedule pathway if patient can't make it — don't drop off the schedule
  • Track no-shows; patients who repeatedly miss visits warrant a phone call to check in
Urgent — call within 24–48 hours Concerning but not emergent
New skin break, mild redness or warmth, painful new corn, suspected fungal infection, question about home care. Patient calls; you (or the practice) respond same business day or next morning.
  • Direct phone number, voicemail option, ideally messaging portal
  • Defined response window (state explicitly: "we return calls within X hours")
  • Triage protocol: who answers, what they ask, when they escalate to the nurse
Emergency — same-day or ER Cannot wait
Spreading infection, systemic symptoms (fever), drainage with foul odor, sudden cold/pale/painful foot, exposed bone, blackened skin. Patient does not call you and wait — they go to urgent care or ER directly.
  • Patient leaves the visit knowing the criteria explicitly
  • Written list of emergency findings stays in their care folder
  • After-hours pathway documented (does not require waiting for clinic to open)
  • Notify PCP and podiatry post-event so the team can coordinate follow-up
Handoff To another provider during a transition
When the patient moves into hospital, rehab, home health, or out of your care entirely. Continuity depends on a structured handoff — the receiving team needs the same information you've been working with.
  • SBAR-style summary to the receiving team
  • Current IWGDF risk category, recent findings, active interventions
  • Footwear/orthotic status, sterilization-relevant info if home care will continue
  • Patient education status: what's been taught, what's been retained
"What if I'm wrong?" is not a reason to delay calling

Patients often hesitate to call because they don't want to "bother" the nurse or aren't sure if it counts. The reframe (taught explicitly in Module 6 and reinforced here): the cost of an unnecessary call is small. The cost of a delayed call — especially in diabetic neuropathy, PAD, or immunocompromise — can be limb-threatening. Make sure your communication pathway is genuinely accessible: a number patients actually call, a portal they actually use, hours they can actually reach someone.

Transitions of Care

Patients move across the care system constantly — admissions, discharges, specialty referrals, home care episodes. Each transition is a moment where information can be lost. Foot care nurses with structured handoff practices catch problems that fall through the cracks.

Common transitions and what to communicate
PCP coordination The default loop, every visit
What to send Note copy after every visit summarizing findings, IWGDF risk category, interventions, and follow-up plan. Quick to do; high yield.
How EMR shared note, fax, or secure email per the practice's setup. Same template every time so the PCP knows where to find each piece.
Hospital admission Acute care, surgery, observation
What to send Brief summary to the admitting team: current foot status, IWGDF risk, active interventions (offloading, dressings if any), home care plan, sterilization log if relevant.
How Phone call or messaging portal; follow up with written note. Reach out at admission if you can; otherwise as soon as you learn about it.
Hospital discharge Returning to home or rehab
What to receive Discharge summary, any new diagnoses, new medications (especially anticoagulants or steroids), wound or surgical status, weight-bearing restrictions, follow-up appointments.
How Schedule a foot care visit within 1–2 weeks of discharge for high-risk patients; reassess plan based on what changed during the admission.
Home health transition Skilled home health nursing involvement
What to share Active interventions, sterile field setup needs (if home foot care continues), patient education status, contact pathway for the home health team to reach you with concerns.
How Direct nurse-to-nurse handoff; written care plan; clear expectations about who does what (nail care, dressings, education reinforcement).
Specialty referral Podiatry, vascular, wound care, endocrinology
What to send Reason for referral, specific question (or specific findings), urgency level, what you've already tried. Use SBAR format for urgent referrals.
How Don't just hand the patient a phone number. Send the note; coordinate the appointment if possible; close the loop after the patient is seen.
End of nursing care Move, change of provider, transition to podiatry-led care
What to send Comprehensive summary of the relationship: history, IWGDF risk category, longitudinal trends, current interventions, footwear/orthotic status, patient education status, what's worked and what hasn't.
How Final visit dedicated partly to handoff documentation; warm-handoff phone call with the receiving provider when possible.

When to Revise the Plan, Not Just Continue It

Plan-revision triggers — events that should change the approach
Re-evaluate the entire plan, not just the next visit
  • New IWGDF risk category change (e.g., new LOPS finding moves Risk 0 → 1)
  • New diagnosis: PAD, neuropathy, autoimmune condition, immunosuppression
  • New medication with bleeding or healing implications: anticoagulants, chronic steroids, biologics
  • Hospitalization or surgery — especially of the foot/leg or vascular system
  • First episode of foot ulceration (regardless of healing) — patient now Risk 3 by definition
  • Recurrent calluses or pressure points despite footwear correction
  • Change in mobility, gait, or self-care capacity (new walker, post-stroke, fall)
  • Cognitive change affecting self-inspection or adherence
  • Caregiver change — new primary caregiver needs full education from scratch
  • Pattern of missed visits or repeated late presentations of complications
  • Change in living situation (move, loss of housing, transition to long-term care)
  • Patient or family report of declining trust or comfort with the current plan

Communication Scripts for Follow-Up

Foot care nurse — follow-up scripts
Setting the next-visit interval with rationale
Based on what we found today — your sensation testing showed some changes — I'd like to see you back every 8 weeks instead of the annual schedule. The reason is that catching small changes early matters more now than it did before. Does that interval work for you?
Why it works: Specific reason tied to the finding; framed as adjustment to your situation, not a generic protocol; invites the patient into the schedule decision.
Confirming the call pathway at end of visit
Before you go — let's make sure you know how to reach me. The number on this card works during business hours. After-hours, the message system goes to the on-call nurse. For anything that can't wait — spreading redness, drainage with smell, fever, sudden cold or color change in the foot — you go to urgent care or the ER without calling first. Can you walk me through what you'd do if you noticed drainage on your sock tomorrow?
Why it works: Explicit pathways for each tier; teach-back at the end to confirm understanding; concrete example.
Notifying PCP about a finding
Hi Dr. Patel, this is [name] from foot care nursing — I saw Mr. Garcia today for his routine visit and wanted to flag two things: he's now testing positive for loss of protective sensation at three sites bilaterally, which moves him to IWGDF Risk 1. Pulses still palpable, no PAD findings. I've adjusted his foot care interval to every 8 weeks and reinforced inspection education. Sending the note — would you like me to flag this at his next diabetes visit?
Why it works: Identifies sender, summary of findings, specific implications, what you've done, what you're requesting from the PCP. Brief but complete.
Asking the patient about adherence without judgment
Tell me how the daily inspection has been going. What part has been easy? What part has been harder?
Why it works: Open-ended; assumes some adherence (many patients hide non-adherence when asked yes/no); affirmative tone ("what's working") before exploring barriers ("what's been harder").
Re-engaging a patient who missed visits
I noticed you haven't been in for a few months — I just wanted to check in to see how things are going with your feet, and to let you know that whenever you're ready to come back, we can pick up where we left off. No judgment. What would make scheduling easier?
Why it works: Outreach without shaming; opens the door without pressure; surfaces barriers (transportation, cost, scheduling). Patients who feel judged stop coming back; patients who feel welcomed often re-engage.

Case Studies

Case Study 1
When the plan needs revision, not continuation
Patient68-year-old man with type 2 diabetes (10 years), previously IWGDF Risk 0, on annual foot exam schedule with self-directed foot care. Recently started on direct oral anticoagulant (DOAC) for new atrial fibrillation.
What changedAt his routine annual exam, monofilament testing revealed new failure at 3 of the 4 standard test sites bilaterally — new LOPS. PCP confirmed the new anticoagulant medication.
Plan revision (not continuation)
  • Reclassified IWGDF Risk 0 → Risk 1 based on new LOPS finding
  • Increased visit frequency: from annual screening + self-care to every 8 weeks foot care
  • Adjusted technique for anticoagulant: lower threshold for conservative trim; hemostatic gauze available
  • Reinforced LOPS-specific patient education from Module 6: drainage and odor as warning signs since pain may be absent
  • Added inside-sock check to evening routine
  • Sent note to PCP confirming new IWGDF risk category and the changes to the foot care plan
  • Coordinated next-visit timing with anticoagulant clinic checkups when possible
  • Patient teach-back confirmed understanding of new schedule and warning signs
Case Study 2
A complete handoff after a hospital admission
Patient74-year-old woman, IWGDF Risk 3 (T2DM, neuropathy, prior toe amputation), on scheduled every-4-week foot care. Hospitalized for cellulitis from a small lateral malleolus wound that wasn't on the foot care nurse's radar.
What happened during admission5-day admission, IV antibiotics, wound care team consulted, started home health for wound dressing changes. Discharged with a new offloading boot and revised footwear restrictions.
Structured re-entry to foot care
  • Foot care nurse received discharge summary; called the home health nurse for warm handoff
  • Scheduled foot care visit within 1 week of discharge (vs the standard 4-week interval)
  • Reviewed: hospital course, wound care plan, new offloading device, follow-up appointments with vascular and wound clinic
  • Coordinated visit timing with home health so dressing changes and foot care didn't conflict
  • Adjusted footwear plan to accommodate offloading boot — paused therapeutic shoe use until cleared
  • Educated patient and daughter (caregiver) on how to inspect skin under the boot and around the wound
  • Sent updated note to PCP, vascular, wound care, and home health summarizing the revised plan
  • Documented: "Plan revised post-hospitalization; coordination with home health, vascular, wound care; teach-back confirmed for revised inspection routine"
Lesson Summary
What every foot care nurse should master in follow-up planning
  • Set visit intervals using the IWGDF framework, not a single one-size-fits-all schedule — and remember screening interval ≠ foot care interval
  • Build every plan with the six elements: findings, home routine, next visit, when-to-call tiers, coordination, and revision triggers
  • Make the between-visit communication pathway explicit, accessible, and tiered (scheduled / urgent / emergency / handoff)
  • Coordinate with the rest of the care team systematically — PCP after every visit; structured handoffs at every transition
  • Recognize plan-revision triggers (new diagnoses, new meds, hospitalizations, ulcer history, mobility changes) and re-build the plan rather than continuing it on autopilot
  • Re-engage patients who fall off the schedule with curiosity and without judgment — most return when the door is open

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Educational Disclaimer

This lesson is provided for professional continuing education and informational purposes only. It is intended to support knowledge development in foot care nursing and does not constitute clinical advice, legal advice, or regulatory guidance.

This course content does not replace, supersede, or serve as a substitute for: the California Board of Registered Nursing (BRN) Nurse Practice Act and current BRN regulations (rn.ca.gov); California state laws and health codes governing nursing practice; county and local public health department requirements applicable to your practice setting; your facility's policies, protocols, and procedures; or your individual scope of practice as defined by your nursing license, credentials, and employer authorization.

Verify before practicing. Clinical guidelines, regulatory requirements, and scope-of-practice rules change over time. You are responsible for verifying all clinical information against current BRN regulations, California law, county requirements, and your facility's policies before applying any content from this course in practice. When in doubt, consult your supervisor, your facility's compliance team, or the California Board of Registered Nursing directly at rn.ca.gov.

References

  1. International Working Group on the Diabetic Foot (IWGDF). IWGDF Guidelines on the Prevention and Management of Diabetes-Related Foot Disease. 2023.
  2. Bus SA, Lavery LA, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews. 2020;36(S1):e3269.
  3. American Diabetes Association. Standards of Care in Diabetes — Foot Care. Diabetes Care. 2024;47(Suppl 1).
  4. Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive Foot Examination and Risk Assessment: A Report of the Task Force of the Foot Care Interest Group of the American Diabetes Association. Diabetes Care. 2008;31(8):1679–1685.
  5. Institute for Healthcare Improvement. SBAR Communication Tool. (Standard handoff communication framework.)
  6. Joint Commission Center for Transforming Healthcare. Improving Transitions of Care: Hand-off Communications. Oakbrook Terrace, IL; 2012.
  7. Wound, Ostomy and Continence Nurses Society (WOCN). Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. 2012 (and subsequent updates).
  8. Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. 2003;51(4):556–557.
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