Not just a nuisance, no-shows are an opportunity to turn things around for patients with bipolar disorder, whose treatment adherence hovers around 60%.
No-shows are not just a nuisance for practice management. They are an opportunity to turn things around for a poorly understood group of patients: the ones who don’t come in. This is where the action is for conditions like bipolar disorder, where treatment adherence hovers around 60%. Innovative practices have developed patient-centered approaches to the problem, and they are seeing improvements not just in attendance but in the health of their patients and the satisfaction of their employees.
New patients have high rates of missed appointments (40% to 50%), and the longer they have to wait for that first visit, the more those rates go up. To address this problem, a public mental health center in Los Angeles created a walk-in system that allowed new patients to come in for their visit on the day they called. No-shows fell from 52% to 18%, and the need to hospitalize patients at their first visit dropped—by a remarkable 13-fold.
Groups at increased risk for no-shows: 1. New patients (the first 3 visits) 2. History of missed appointments 3. Long delay between the act of scheduling and the actual appointment 4. Younger patients (age 20-39) 5. Addictions and multiple comorbidities 6. Recent hospitalization 7. Medicare and Medicaid plans 8. Unemployed or low socioeconomic status 9. Transportation problems 10. Treatment by a resident in academic settings
“Patients told us it was difficult to ignore a personal call.” Though they may beat us at chess, computers have yet to outperform the personalized call when it comes to appointment reminders. No-show rates improved 40% when a live person made the call, but the improvement was only 30% when the reminder was automated, according to a meta-analysis. If your practice lacks the resources to make those calls, try a limited roll-out for high-risk cases like those above.
A surprising number of patients know that they can’t make their appointments but neglect to cancel them. Scheduling conflicts are challenging for most people, and symptoms such as ambivalence, avoidance, and cognitive dysfunction don’t make it any easier. The process can be improved with online scheduling, personalized reminder calls, increased scheduling staff, and even the motivational interview.
Most practices have some repercussions for no-shows, such as charging a small fee ($20-$50) or terminating care after 3 missed appointments. There’s evidence supporting both approaches, especially when the policies are discussed directly.[1,5] Both have unique drawbacks as well. The American Psychiatric Association warns that missed appointment fees “should be resorted to infrequently and always with the utmost consideration for the patient and his or her circumstances.”
Some practices overbook their schedules to compensate for no-shows, but this can create a vicious cycle. The inevitable appointment conflicts lengthen wait times, and that in turn increases the risk of future no-shows On the other hand, occasional overbooking may be appropriate in a large practice with a high no-show rate and urgent cases that need to be fit in. Dynamic booking is a strategic form of overbooking that uses computer modeling to minimize the risks of appointment collisions. It can bring that risk down to 5%, but not to zero.
What about patients who don’t reschedule their missed appointment? This is where it gets tricky. To reduce their liability, most psychiatrists send a termination letter, clearly specifying when their availability will end. On the other hand, these are the patients who most need our availability. Around 20% of psychiatric patients drop out of treatment prematurely, and they carry a high suicide risk. The “postcard” studies offer a unique solution to this dilemma.
Can a simple postcard prevent suicide?
That question has been tested in a dozen randomized controlled trials, and the answer is a tentative yes. The results were not uniformly positive, but a recent meta-analysis concluded that a supportive card or phone call lowered the frequency of suicide attempts by 34%. The studies involved subjects who presented with suicidality to an urgent care or hospital facility. Although different from the outpatient population we have in mind, they shared this important characteristic: most had declined ongoing care. The cards offered a supportive, welcoming, non-intrusive message, as in the example above. They are an antidote to the disconnection, self-reproach, and hopelessness that severe depression brings. You can send them out on their own or incorporate them into a gentle termination letter. Either way, don’t use a real postcard; follow the study protocol and wrap them sensibly in a HIPAA-compliant envelope.
Dr. Aiken is the Director of the Mood Treatment Center and an Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He does not accept honoraria from pharmaceutical companies but receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, which he coauthored with James Phelps, MD.
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