Just about everyone agrees that treatment adherence is a significant public health problem in the United States. As healthcare reform discussions evolve, the importance of adherence in the face of limited resources is getting more attention than it has heretofore.
Clinicians think about “adherence” from many perspectives. It involves any client behavior that may be related to treatment-from keeping appointments and following through on a therapist's recommendations to taking medications as prescribed.
In 2003, a study by the World Health Organization estimated that only 50 percent of patients suffering from chronic diseases in developed countries follow treatment recommendations.1 These figures ring true in behavioral health populations suffering from long-term illnesses like depression, bipolar disorder, and schizophrenia. Treatment nonadherence remains one of the greatest challenges in the field of behavioral health. In this article, we'll look at one of the most basic forms of nonadherence: the missed appointment.
In clinical settings, practitioners can spot telltale signs that a consumer is not adhering to the treatment plan, even before the patient exhibits the clinical consequences, which may include disease progression, diminished function, increased family burden, and more.
The famous Woody Allen quote—Eighty percent of success is just showing up—applies here. One early, obvious sign of nonadherence is a patient's failure to show up for an appointment.
Gail Lawson, PhD, is CEO of Sound Community Services (SCS) in New London, Connecticut, a private not-for-profit mental health clinic that provides more than 2,000 outpatient appointments per month. “As CEO, I became very concerned when I learned that our clinical staff was experiencing a 30-40 percent no-show rate,” said Lawson. “Since our staffing costs are fixed, no-shows mean lost revenue as well as less consistent care and poorer client outcomes.”
To tackle the problem of missed appointments, Lawson ordered the implementation of a client appointment-reminder system in August 2007-one month after SCS installed its electronic health record (EHR) system. This auto-call system eliminated the need for a long list of daily reminder calls by administrative staff which, according to Lawson, were difficult to schedule and complete consistently.
SCS obtained the auto-call system by contracting with a HIPAA-compliant service provider. Each day, SCS staff sort appointment records in the EHR and download a comma-delimited data file. When this file is uploaded to the auto-call system, the system makes calls to consumers two days before their scheduled appointments. During each call, the consumer who answers is asked to press “1” to cancel or “2” to confirm the appointment. When the call cycle is completed, the automated call system provides the results of successful calls, including any voice messages offered by the consumers, along with a list of unanswered calls.
By midday, when the call cycle is completed, the office manager reviews the auto-call results and adjusts the appointment schedule accordingly. Cancellations are easily filled, staff is alerted to possible consumer problems, and decisions can be made about how to manage appointments for consumers who did not answer their calls.
SCS's Medical Director, Dr. Kathleen Degen, has monitored the reminder-call process for effectiveness.
“We have trained the office manager to fill vacant appointment slots based on response (or non-response) to the auto-calls. I would estimate that our no-show rate was cut in half after the implementation of the auto-calling system,” Degen said.
Degen notes that on occasions when expected calls were not made, “I have seen the patients complain that they did not get a reminder, and we notice an increase in ‘no shows.’ This speaks to how well people like it. No one has said that they dislike it-even people with irritability or paranoia.”
Lawson feels that the return on the investment is well worth it-she estimates the typical monthly bill for auto-call confirmations of more than 2,000 appointments to be about $100. “Dentists and other healthcare professionals do this. Why not us?” Lawson asked.
Family Services of Western Pennsylvania (FSWP) is a community oriented not-for-profit behavioral health services provider headquarted in Pittsburgh. A few years ago, FSWP leadership noted that “we were getting more clinicians that followed protocols but were not good at engaging people,” said FSWP's CEO Stephen Christian-Michaels.
In 2004, FSWP partnered with researchers from the University of Pittsburgh to study and develop consumer engagement strategies. Like SCS, FSWP was concerned with high no-show rates in its outpatient clinics. By adapting the work of Columbia University's Mary McKay, the FSWP-Pitt research partners developed an “engagement phone interview” for all individuals scheduled for initial assessments.2
To test the effectiveness of these “engagement calls,” FSWP compared consumer attendance rates during a period when the calls were made (February to June 2007) to a period when they were not (February to May 2008). A total of 965 initial assessments were involved and, sure enough, during the period of active engagement calls consumers attended their appointments at a rate of 71 percent, while attendance for consumers who did not receive a call fell to 59 percent. The difference was statistically and clinically significant, Christian-Michaels explains. “At least 75 clients received counseling that otherwise might not have.” He asserts that the engagement call protocol “pays for itself by reducing ‘no-shows’ and improving clinician productivity.”
Both SCS and FSWP have pursued additional tactics to battle the missed appointments phenomenon. FSWP has developed the “engagement group,” which includes consumers who missed two initial assessments or two counseling appointments. The group's purpose is to talk with consumers about the value of assessments and treatments and establish understandable goals and expectations for the services. Christian-Michaels felt that “this psychoeducational approach helped to dispel misperceptions and misunderstandings about therapy.”
While SCS has successfully reduced its no-show rates by using the auto-call reminder system, the organization still insists on “live” reminder calls to consumers who have scheduled their first-visit appointments.
According to Lawson, “In the old days, it was a very cumbersome task to expect secretarial staff to identify all of the upcoming client assessments and contact these people in advance. The procedure was erratic at best, and the success of the phone call depended on a given secretary's telephone skills.”
SCS has since developed a best practice for live, first-visit notifications that combines available technology and clinical common sense. “We wanted our clients to understand that the time allotment for a first-time evaluation is a precious commodity,” Lawson explained.
SCS staff agreed that a scripted call format would be the best approach. The script explains in clear language that the clinical staff's time is very limited and that a missed first appointment would lead to the client having to attend an “intake group” and re-start the administrative procedure, resulting in the need for extra visits before they actually are seen by one of the staff physicians (see figure 1).
Organizations like SCS and FSWP present leading models for confronting the realities of scarce behavioral healthcare resources. Engagement is not merely a cost saver. It allows quality care to occur and, in the case of these two clinics, offers an opportunity for dialogue with clients about the realities of scarce resources. Engagement means sharing the responsibility of resource allocation with the client. By understanding that a time slot for evaluation or treatment is an expensive commodity, consumers of behavioral health services will partner with providers effectively to help preserve the goal of protecting the quality of care and cost of service delivery.
"Your intake is scheduled for [date], at [time].
It is very important you keep this first appointment.
If you cancel or do not show for this appointment you will not be given another appointment.
Should you miss the first appointment you will need to attend our admissions group if you want to receive services from this agency.
In this group you will complete all admitting paperwork before you are given another appointment with a counselor to complete your intake.
This means it will take three appointments to see a doctor which is why we encourage you to keep your first appointment.
By keeping your first appointment you will complete your intake with a counselor and then be given a second appointment to see the doctor."
Provided by Sound Community Services, New London, CT
Behavioral Healthcare 2010 March;30(3):28-30