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Pearls


Help your patients keep appointments

Vol. 6, No. 12 / December 2007

Patients’ failure to keep appointments is a common problem. On average, patients miss approximately 15% of follow-up psychiatric appointments,1 but the percentage is much higher in some patient populations, such as patients with significant socioeconomic difficulties. Those who miss appointments often have worse outcomes and even a higher likelihood of psychiatric readmission.2

We present strategies to help patients keep appointments and to handle occasional and repeated absences. Although the problem of missed appointments will never go away, following these suggestions could help minimize it.

Prevent the problem

Explain to the patient why regular appointments are important. The most important point is that clinician and patient must agree that—to best help the patient—treatment requires that all appointments be kept, barring emergencies.

Communicate clearly. Avoid emphasizing rules, such as that patients must keep 80% of appointments, give 48-hours’ notice for cancellations, or pay a no-show fee. These suggest that patients may miss appointments as long as they follow the rules.

Fix structural problems in your practice that may be barriers to making, rescheduling, or cancelling appointments. Be clear with patients about:

  • the phone number they should call for appointments
  • if they or you must cancel, that person is to reschedule at the earliest opportunity.

To avoid phone tag, ask the patient to provide a mobile phone number. If you are unable to reach the patient, leave a message with 2 potential times you could see the patient and ask the patient to call back to confirm one of these times.

If the patient is missing appointments because the frequency is too burdensome, in many cases less frequent but more regular visits may be better.

During your early sessions with patients, be sure they understand that you reserve specific times for them. Make sure, however, that patients don’t interpret this to mean that attending every appointment is for your benefit, rather than important for their treatment.

Emphasize responsibility. At the end of each session, set a goal with patients for the next appointment. With a patient who has missed appointments, ask for a commitment that he or she will come to the next session. We have found that stating that you are concerned the patient might not come to the next session can paradoxically be helpful.

Having your receptionist call and remind patients the day before their visits might not be a good idea in many cases. Patients might think these calls relieve them of the responsibility for remembering to keep appointments.

With patients you think might miss appointments—especially those on a medication that requires careful monitoring—consider writing prescriptions to last no longer than the next appointment.

Occasional missed appointments

Don’t just let it go when patients occasionally miss appointments without adequate reason. Ignoring the problem lets it progress.

Resist the temptation to be courteous and say, “That’s all right” when patients apologize or give a reason for missing the session. Doing so gives a subtle message that missing appointments is acceptable.

Discussing the patients’ reasons for missing appointments might solve the problem at times. For example, patients might not mention transportation or child care problems.

Note in the chart when a patient does not come to an appointment so you can calculate how many have been missed. This notation also will remind you to address these missed appointments during the next visit. Because discussing missed appointments at the start of the session might seem confrontational or punitive, inquire about the reasons for missing the previous appointment in a gentle manner and later in the session.

Remind patients that therapy is the tool to solve their emotional problems and thus has a special place in their lives. If patients want to solve other problems, they must start by regularly attending therapy.

Repeatedly missed appointments

When a patient misses appointments repeatedly, take 1 or more sessions to discuss it. This has to be done before therapy can proceed effectively (of course you might need to postpone this discussion if the patient has experienced major stressful events or has other pressing clinical issues).

When doing this, resist the temptation to become sidetracked by other issues the patient brings up. You can let the patient vent for a few minutes, but don’t let most of the session go by before addressing the missed appointments.

References

1. Mitchell AJ, Selmes T. A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United Kingdom. Psychiatr Serv 2007;58(6):868-71.

2. Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. Br J Psychiatry 2000;176:160-5.

Dr. Mago is assistant professor of psychiatry and director of the mood disorders program; Dr. Mahajan is a research volunteer; and Dr. McFadden is an instructor and associate director of adult outpatient services, Thomas Jefferson University, Philadelphia.

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