In research literature, the rate of missed appointments of people seeking health service always appears to be highest among people with mental health or addictions issues. In our (admittedly limited) search, the highest rate found was 64% (Compton et al., “Predictors of Missed First Appointments at Community Mental Health Centers After Psychiatric Hospitalization,” Psychiatric Service 2006).
In Toronto, Concurrent Disorders Support Services (CDSS) provides access to a partnership of 20 medical and community-based organizations serving persons with a concurrent disorder (co-occurring mental health and addictions issues) and complex needs (homelessness/ at risk, no/ low income, multiple problems). We have found that without support up to 70% of our clients miss appointments.
In the literature, why clients miss appointments is:
- Long wait time.
- Forgot, inconvenient time, could not change it.
- Lack of a stable place to stay.
- No established link to the service.
Clients also miss appointments due to attitudinal issues:
- Leaving previously against medical or other advice.
- Fear and anxiety in anticipation of procedures and bad news.
- Lack of information or choice in their treatment plans.
- Felt disrespect from health care providers.
Recommendations to reduce missed appointments were:
- Reduce wait time.
- Provide open access (same day) scheduling.
- Provide reminders.
- Strengthen the alliance between the treatment providers and client.
- Put the clients’ goals at the centre of planning.
- Enhance client’s “insight” [information?] regarding treatment.
- Engage family/ peer supports in planning.
- Establish a transitional link between this and other services.
- Establish a stable place to stay [CDSS experience].
- Train workers to provide a welcoming atmosphere, prevent client fears and reduce penalties regarding missed appointments [CDSS suggestion].
CDSS's Experience
CDSS was entering its second year of operation when it was hearing from some of its partners that clients were not making it to their first appointments, despite fast-tracked service (typically, a one to two-week wait).
When CDSS did a survey of referred clients (April through September 2008), it found that only 30% had made it to their first appointments, due to cancellations and no-shows. The most frequent reasons given were “changed their mind” or “lost contact.” The worst rates occurred with referral to psychiatric consultation and withdrawal management. Finally, of those who did attend their first appointment, only 50% “completed” the program.
Although staff of CDSS realized that the high rate of missed appointments reflected the usual situation with a “CD-complex” clientele (as partners’ workers confirmed), it was shocking that so much energy was being expended for so little carry-through.
Through various means, CDSS staff communicated the issue to partners and started making some changes by:
- Requesting more information on the referral form regarding clients’ contacts, including family, shelters and external workers.
- Connecting with clients prior to hospital or residential discharge.
- Connecting with external providers as necessary, even those who were not participating in the the partnership.
- Requiring accompaniment to the first appointment.
When CDSS did a follow-up survey October 2008 through March 2009, it found considerable improvement, with 76% attending the first appointment. The conclusions were:
- Relatively simple steps could make a significant change in access.
- The partners, coming from different professional backgrounds, were discouraged by no-show, but were frequently neither focused on nor clear about how to improve it.
- Without adjustment in their requirements for complex clients, health and social services were losing significant appointment time to patients/clients, whether prioritized or not, with longer wait for mainstream clients.
- A new form of measuring outcome was needed, as “completion” (the term used in the PSR Toolkit and Common Data Set) was not appropriate for a CD-complex population.