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In this second of the series of questions and answers about the Partners for Change Outcome Management System and the challenges of public behavioral health, Mary Haynes, Ph.D. tackles cancelations and no shows and discusses how PCOMS can have a positive impact on missed appointment rates. For more information, visit the Public Behavioral Health page at www.heartandsoulofchange.com

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  1. 1. Dr. Barry L. Duncan, Director_______________________________________________________________________ CDOI Training and Implementation of the Partners for Change Outcome Management System Public Behavioral Health and PCOMS: Questions and Answers 2. No shows and cancellations are a much bigger problem in PBH than in private practice, given that poverty and general life chaos are more likely in the population we serve. How do we use CDOI/PCOMS to reduce no shows and cancellations? Client cancellations and appointments not kept without notice are the bane of both clinicians and administrators in public behavioral health agencies. Agencies often work very hard to reduce the rates, which can be as high as 50% or more, because the consequences impact every level of the organization. When rates are excessive, administrators have difficulty managing both budgets and programming, clinicians cannot meet their direct service target hour requirements or efficiently manage their time, and support staff spend large amounts of time trying to reschedule clients who may not be easily reachable. In many agencies clinicians schedule clients for all of their available work hours (and sometimes lunchtime as well) and yet still do not meet target hour requirements because of cancellations and no shows. Worst of all is the possibility that the clients involved are not receiving effective treatment, whether that is the cause or the effect of excessive cancellations and no shows, and people who would like to receive services may have to be placed on waitlists because of schedules clogged with clients who use services on an unplanned intermittent schedule. PBH’s have used a variety of practices to reduce the level of no shows and cancellations. Most of the research on no shows and cancellations has focused on changes in policy or administration actions. Administrative practices such as reminder calls, designated weekly appointment slots for clients, and scheduling intake appointments within a week of the request for service are often the first consideration. These practices keep clinicians’ schedules full, but do little to improve the actual show rate. Clinical practices such as conversations with clients at the time of intake about the importance of keeping appointments and information about the consequences of failure to come to sessions, along with brainstorming with clients about possible solutions to barriers to attendance are sometimes used, with varying success. A 2010 study on missed appointments by Defife, Conklin, Smith and Poole published in Psychotherapy1 reported that 28% were attributed to physical illness, psychiatric hospitalization or substance abuse, 26% to practical issues such as work conflicts, transportation or inclement weather, 17% to motivational problems and 13% were attributed to treatment-related issues such as avoidance of intimacy, negative reaction to a diagnosis or treatment modality, or disagreement about goals. The information on reasons for missed appointments was gathered only from clinicians, not directly from clients, so it is hardly surprising that, at a minimum 30% of missed appointments were attributed to client failures to participate appropriately. Clinicians were asked for the client’s stated reason for missing the appointment and their own thoughts about the reason for missing. In contrast to other research on this issue, this study did identify treatment-related issues as contributing to missed appointments, but 0% of the attribution was made to clinician contributions.PO Box 6157, Jensen Beach., FL 34957; 772.204.2511; 561.239.3640; barrylduncan@comcast.net
  2. 2. 2In fact, those of us who work in PBH agencies know that cancellation and no show rates vary widelyfrom clinician to clinician, even within the same office. Since all clinicians are working with the samepopulation and within the same administrative procedures, these differences can only be attributable toclinician factors.Both the research and our agencies’ experiences tell us that the use of CDOI practice/PCOMS is veryuseful in addressing and reducing the discrepancies between clinicians in regards to effectiveness, andthe same is true for no show and cancellation rates. CDOI practice helps us to privilege clients’ goalsand theories of change, to emphasize the common factors over the use of models and techniques, andto regularly measure and discuss with clients both progress toward goals and the quality of the alliance.All of these practices not only lead to more rapid goal attainment but also enhance clients’participation, thereby reducing no shows and cancellations (Bohanske & Franczak, 2010)2Client cancellations and no shows are in large part a quality issue and should be addressed as such.Even reasons categorized as practical issues in the Defife et al study, and likely some of thosecategorized as medical problems as well, are in part influenced by the quality and value of the service.Here are some ways to use CDOI/PCOMS practice to reduce no shows and cancellations: • Determine the current rate of no shows and cancellations by both site and individual clinician • Make sure that everyone is reporting no shows and cancellations in the same way. It doesn’t have to be a perfect system—in fact it can’t be because of all the factors involved—but just make sure that there is consistency so that comparisons are possible. For example, make a determination about whether or not an appointment not kept on the scheduled day and time but is made up within the same week will be considered a no show/cancellation, and make sure that decision is communicated to staff. Ask staff to help you think of all of the contingencies so that you’re reasonably sure you have the bases covered before you start any comparisons. • If you’re pretty certain that there is already a common way of reporting no shows and cancellations, that’s ideal because you can start right way letting staff know that you’re going to focus on bringing the rate down. Just letting staff know that you will be paying attention to the problem will bring the rate down, so if you have to develop consistent standards before you start, keep in mind that you will have already started to lower the rates. It’s kind of like physics that way—just studying the problem creates a change in the system, which in turn changes the outcome somewhat. • Determine the site baseline average and for each clinician. • Let staff know where they fall in relation to the site average and in relation to other staff. You don’t need to identify which clinician is which, but it’s helpful to let all staff know what the highest and lowest rates are, as well as the average for their program or setting. Most clinicians want to do better than average, and will work hard to perform at a higher level. • Make sure that you have addressed the policy and administrative issues first. This will help staff know that you are interested in doing what you can to take responsibility for the problem and will provide them with the administrative support they need to do their jobs. For example, if possible make sure that a support staff is available at all times to take client phone calls so that cancelled appointments can be rescheduled when the client calls. This saves the burden of trying to reach clients on a callback and better ensures that staff schedules can be filled. • Make sure that support staff who interact with clients on the phone or in person have good relational abilities and interact skillfully with clients who present in a variety of ways. Support staff are usually the first people to interact with clients, so they should make a good representation of your agency’s values and style.
  3. 3. • To cut down on no shows/cancellations for intake appointments (which are even higher than the rates for established clients), consider training support staff to administer the ORS over the phone at the time of the initial call. This communicates right from the start that services are dedicated to eliciting clients’ ideas and helping them reach goals. • If the initial appointment at your agency typically focuses on gathering information required by licensing and insurers, make sure that time is set aside during the session for the client to speak at some length about their most important concern. Clients are more likely to return for a second appointment if they got even one thing that was useful to them out of the first. • Make no show/cancellations a focus of supervision, as tied into the clinician’s PCOMS data. With the supervisee, carefully monitor client distress and alliance problems in regards to those clients who no show/cancel with even moderate frequency. • Consistent with CDOI practice, encourage staff to be particularly mindful of relationship with clients who no show/cancel more than rarely. • For example, the therapist on my staff with the lowest no show/cancellation rate makes her own follow-up calls to clients who fail to keep an appointment. She calls and if necessary leaves a message that she really missed seeing them that day, looks forward to seeing them again, and encourages them to reschedule. Her clients report that they feel valued and wanted, and this makes all the difference to them in getting to their scheduled appointments. This only takes a few minutes of her time between appointments or at the end of the day, but pays big dividends. Not surprisingly, not only does this therapist have the lowest no show/cancellation rate but she also has the highest percentage of clients who reach benchmark. • Ask staff who have low rates what they do to keep their rates low and share their ideas with the rest of the staff. • For clients how no show or cancel frequently, encourage clinicians to discuss changing their appointments to fit the pattern of their actual attendance. • As in the Defife et al study, few clinicians will attribute no shows/cancellation rates to their own behaviors and interactional style. However, those who come to understand their role in the problem will have more rapid and larger improvements in reducing their rates. • Communicate to staff that you view no show/cancellation rates as a quality issue, and consider incorporating some standards into performance evaluations. Sitewide average rates will decrease as clinicians become more skillful at reducing their rates, so rather than using a specific percentage or range in performance evaluations, use language reflecting your expectations for clinicians in relation to the prevailing site average. 1 Defife, J.A., Conklin, C.Z., Smith, J.M., & Poole, J. (2010) Psychotherapy Appointment No- Shows: Rates and Reasons, Psychotherapy Theory, Research, Practice, Training, 47, 413-417. 2 Bohanske, R., & Franczak, M. (2010). Transforming public behavioral health care: A case example of consumer directed services, recovery, and the common factors. In B. Duncan, S. Miller, B.Wampold, & M. Hubble (Eds.), The heart and soul of change: Delivering what works (2nd ed., pp. 299-322). Washington DC: American Psychological Association. Written by Mary Haynes, with input from David Hanna, Jodi Daly, & Bob Bohanske.PO Box 6157, Jensen Beach., FL 34957; 772.204.2511; 561.239.3640; barrylduncan@comcast.net