Structuring Follow Up: The First 90 Days

The initial consultation receives most of the attention in functional practice: the long history, the timeline, the matrix and the plan. Yet the outcome is usually decided later. Many plans fail not because they were wrong but because follow up was absent, irregular or unfocused. The first 90 days are when new habits either form or fade, when side effects and interactions appear, and when early results either encourage or discourage the patient. Structuring this period deliberately makes a large difference.

Why 90 days

• Habit formation research suggests that new behaviours take around 2 months on average to become automatic, with wide variation.
• Many biomarkers take weeks to months to change: HbA1c reflects about 3 months, ferritin responds to iron treatment over several weeks, and lipids stabilise over 6 to 12 weeks after dietary change.
• Early adverse effects, interactions and practical barriers usually appear in the first few weeks.
• Motivation is typically highest at the start and most fragile after the first month.

A structured sequence

The exact timing will vary with the condition and the patient. Patients with medication changes, safety concerns or complex needs may need closer contact.

What happens at each review

Review adherence without judgement

Ask what the patient has been able to do, what has been difficult and what they have learned. Framing lapses as information rather than failure keeps the conversation productive.

Check safety

New symptoms, adverse effects, supplement reactions and medication related changes such as low glucose or dizziness.

Review measures

Compare agreed outcome measures with baseline: symptom scores, weight, waist, home readings, activity, sleep.

Adjust

Keep what is working, modify what is not and consider whether the next change is appropriate. Avoid adding too much at once.

Update the picture

New information from the patient or tests may change the timeline, the matrix or the priorities.

Between visits

Support between appointments often determines success. Options include:

• health coaching sessions focused on behaviour change;
• simple tracking tools, such as checklists, food and symptom diaries, step counters or glucose readings;
• brief secure messages for questions;
• educational materials and recipes;
• group programmes where available.

Clear guidance about when to contact the practitioner or seek urgent care, known as safety netting, should always be given.

When to retest

Retesting too early can produce misleading results and discourage patients.

Handling setbacks

• Expect them. Tell patients at the outset that setbacks are normal and do not undo progress.
• Identify the trigger: illness, travel, stress, a holiday, a change in routine.
• Simplify: return to the 1 or 2 most important changes.
• Problem solve together: what would make it easier next time?
• Revisit motivation: why did this matter to the patient in the first place?

When progress stalls

If there is little progress by the 12 week review despite good adherence, reconsider the hypotheses. Is there a missed diagnosis? A mediator not yet addressed? A medicine effect? Is the plan realistic for the patient’s circumstances? Stalled progress is an opportunity to revise the map, and sometimes a reason to refer.

Planning for maintenance

By around 3 months, some patients have met their initial goals. The conversation then turns to maintaining gains, preventing relapse, deciding on the frequency of future reviews, reducing supplements that are no longer needed and setting longer term goals. Maintenance plans are particularly important for weight, where regain is common.

A worked 90 day plan

A 48 year old woman with fatigue, iron deficiency, poor sleep and prediabetes starts her plan. At week one, a coaching call reveals that iron tablets are causing constipation; her doctor switches to alternate day dosing. At week 4, her sleep has improved with a fixed wake time, her energy is slightly better and her haemoglobin has risen; the next change, a protein rich breakfast and a walk after dinner, is added. At week 8, a family illness has disrupted her routine; the plan is simplified to sleep and breakfast. At week 12, her ferritin has improved, her HbA1c has moved back towards normal, her fatigue score has halved and she has lost 3 kg. The next phase adds strength exercise and a maintenance plan.

Follow up is the treatment

Structured follow up is not an administrative extra. It is where plans are tested, adjusted and made to work in real life. A clear 90 day structure, with support between visits and timely retesting, turns a good first consultation into lasting change.