Procedures for CWH follow-up visits

What are your procedures for CHW follow-up visits?  What topics do they cover at each visit?  Is the approach standardized, or more tailored to each client's situation?

We have a set of core topics that we cover over the course of the 4 visits and then tailor additional topics to the needs and interests of each household, using motivational interviewing methods. The list of topics is on our website: http://www.kingcounty.gov/healthservices/health/chronic/asthma.aspx