What happens when patients don't show for your appointments?

Rehab Regs, March 7, 2003

What happens when patients don't show for your appointments?

Maybe Daniel's transportation to your outpatient rehab setting fell through at the last minute. Perhaps Great Aunt Matilda died and, amid the flurry of arrangements, her family forgot to notify you. Or maybe Sam simply forgot about his therapy session.

No matter the cause, patients who fail to keep their appointments for therapy services and provide no advance warning can wreak havoc within your outpatient rehab setting. Affectionately known as "no-shows," these patients can affect your therapists' productivity levels and ultimately your financial bottom line.

Many outpatient rehab providers find themselves engaged in a somewhat philosophical debate at times over whether they can prevent no-shows or, at the very least, cut down on the numbers of missed appointments. The next time you find yourself in such a debate, industry experts recommend that you remember the following:

1. Perform an analysis-and consider target rates. First, it's important for outpatient rehab providers to differentiate between patients who legitimately cancel their appointments and those who are no-shows, says Frances Fowler, president of Fowler Healthcare Affiliates Inc. in Atlanta.

Many providers fail to separate these two populations-each of which may call for different strategies to remedy. By grouping the two together, some facilities may report no-show rates as high as a misleading 25%-30%.

Optimally, all outpatient rehab providers should strive to maintain a no-show rate of 12% and a cancellation rate of 3%-5%, Fowler says.

"You need to get a handle on your numbers," she says. "If you don't have a handle on the numbers, it's difficult to get a handle on your strategy."

Once you've separated the two populations, you should study the number of no-shows and pay special attention to the day, time of day, provider, and type of patient, says Angie Phillips, PT, president and chief executive officer of Images Inc., a health care consulting company based in Amarillo, TX. Often, you'll discover that certain groups tend to have higher no-show rates. One example is the pediatric patient, she says.

"Do a focused review to determine the causes-lack of transportation, working parents, sibling needs that conflict with appointment times, or school attendance issues," Phillips says. "Once you do the analysis, you can start looking at ways that you can improve the attendance."

2. Develop strategies. When you consider ways to prevent no-shows, it's important to remember that it's impossible to prevent every no-show, Fowler says. But you can introduce some simple strategies-depending upon the results of your analysis-that may lower your numbers.

"Once you dissect [your numbers], you can start to figure out the reasons," Fowler says. "Some people have implemented calls ahead-usually a 24-hour notice. This works to some degree, and you'll usually get a response of, 'I'm so glad that you reminded me.' "

You can also target the reminder system toward certain types of patients, Phillips says. "Use appointment cards and reminders," she says. "If you have done the analysis, you will know whether there are patterns of no-shows. If, for example, the no-shows are for new evals, be sure to implement a reminder call system to ensure that they attend the session."

Other outpatient rehab providers may decide to extend the hours of their practice. For example, some providers may open Saturday mornings to accommodate a working population. Others who have noticed a high rate of cancellations and no-shows in the early morning hours, may decide to open later in the day and extend their hours into the evening, Fowler says.

You may also want to consider revamping your policies in order to limit no-shows, Phillips says. "Consider policies that reward attendance," she says.

"Schedule your dependable patients in the premium time slots. For patients with high no-show rates, consider scheduling them one week at a time and based on open slots only. This way you can limit the effect of no-shows on your practice."

3. Make your policies clear to patients. Outpatient rehab providers need to have an attendance policy, inform patients up-front of the policy, and enforce it, Phillips says.

Other providers find it helpful to have patients sign a commitment to attend sessions prior to the start of their regimen, Fowler says.

While the issues of no-shows may sometimes fall more into the realm of compliance, it's important that you plan a swift response to cancellations, says Ken Mailly, PT, a partner in Mailly and Inglett Consulting LLC in Wayne, NJ. The firm specializes in individual, practice, facility consulting, education, practice management, compliance, and reimbursement.

"These are the patients we can try and do something about immediately," Mailly says. "The second time a patient calls to cancel, he or she should speak with the therapist directly, if not on the first cancellation. We, as therapists, need to remember that compliance with a therapeutic program is really no different than taking a prescription. If someone fails to follow the prescribed regimen, that certainly impacts the outcome of that patient. It's immediately a therapeutic concern."

Mailly stresses that it's important that the phone call comes from the therapist-and it should not be delegated as a front-office task. "You're communicating to the patient that you care about the fact that they're not there," he says. "Maybe that cancellation turns into a reschedule. There are multiple benefits to make sure that the therapist speaks with the patient."

4. Consider possible reasons behind high no-show rates. If you've stressed the importance of attendance to patients at the outset and you still see high no-show or cancellation rates, look at the therapist interaction with patients, Mailly says.

"If your no-show rate is quite high, it may be indicative of a larger problem," he says. "It may be an indication of the therapist overtreating, or providing more care than the patient may be benefiting from, or not adequately explaining the importance of compliance with the program."

In short, resist the initial instinct, which may be to act punitively toward the patient, Mailly says. "The first place they need to look is at the patient and therapist interaction," he says. "You need to study how the therapeutic relationship is being established with patients."

5. Look at double-booking. Many outpatient rehab providers-as a way to prevent no-shows or cancellation rates-may decide to practice double-booking or overbooking. The practice is not uncommon, but providers should exercise caution and be aware of applicable CMS regulations.

"Most providers, should they double book, won't schedule patients in the exact same time slot, but will have a 10- or 15-minute overlap," says Fowler. "It's more of a challenge to do this because there are a lot of rules as to what's considered group therapy and what is considered individual therapy."

While outpatient rehab providers may feel as though they're unrealistic in doing this, they can move forward with the results of their analysis in mind, Phillips says. "Consider overbooking to some degree in the time slots that typically result in no-show appointments," says Phillips. "You lower your risk of unused treatment time and, if you overbook carefully, can provide some limited one-on-one or more extensive group activities to meet client needs in slots where everyone shows."

6. What about financial penalties? Should you decide to levy financial fines against no-show patients or cancellations, proceed cautiously, Mailly says.

"I would warn people, as I have been aware of practices in the past in which the patient would be charged a fee covering the entire treatment, even though they weren't there," Mailly says. "That is a very dangerous practice, and no one should consider doing this. It's obvious that with any of these policies or practices [involving fees] that informed consent and advanced notice to the patient is critical, or you will be inviting legal action, in which you could probably lose."

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