Access To Care A Study on Pediatric No Show Rates in a Community Health Center Clinic

1. Access To CareA Study on Pediatric No Show Rates in a Community Health Center Clinic United Community and Family ServicesNorwich, CT Meghan L. Ritz Physician Assistant Student

2. BACKGROUND • A growing child requires frequent preventive health care appointments for: • Assessment of: • Development • Behavior • General well-being • Provision of: • Immunizations • Anticipatory guidance and counseling to parents/guardians

3. BACKGROUND • Assessment of growth and development is based on the Well-Child Visit (WCV) • Number of visits for UCFS is determined by the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) schedule of preventive health services1 • > 8 visits in first 12 months • > 14 visits in first 5 years • > 28 visits by age 21

4. BACKGROUND • Immunizations are important aspect of preventative healthcare for this population • Typically received on date of WCV • > 29 immunizations with first 6 years of life • Follow-up appointments are often necessary to adhere to schedule • Immunization compliance can be used as an indicator for amount of well-child care received by a patient3

5. http://practice.aap.org/popup.aspx?aID=1625&language=

6. BACKGROUND • Non attendance for scheduled appointments is a common problem in pediatric clinics • Disrupts continuity of care • Increases numbers of underimmunized children • Creates a significant misuse of clinic resources • In 1998, the average No Show Rate (NSR) rate for pediatric ambulatory clinics was 31%2

7. No Show Rates at UCFS Barriers to continuity in childhood healthcare exists for this community…but what are they??

8. OBJECTIVES Immediate Long Term Create Initiatives Reduce current pediatric NSR at UCFS by increasing compliance increase continuity of health care received Better utilize available UCFS community outreach programs reduce misuse of resources • Define the Barriers • Understand and identify reasons for failed appointments by pediatric patients

9. METHODS Identify Barriers Create Initiatives Review of available UCFS services Literary review of journal articles on previously conducted studies • FY2010 No Show Rate (NSR) data • Previous daily appointment schedules • Collaboration with UCFS interdepartmental personnel

10. Identify Barriers:Analysis of UCFS NSR Data from FY2010 • Study variables selected from available demographic information • Age • Payment source/insurance provider • Distance from clinic based on patient home town • Designated provider • NSR rate determined from number of missed appointments vs. number of total appointments made for established patients

11. Identify Barriers:Review of Previous Daily Appointment Schedules • Categorize failed appointments • Well Child Visits (WCV) • Office Visits • Including follow-up appointments • Sick Visits • Determine lag time • Period of time between date appointment scheduled and date of failed appointment

12. Results:NSR Data Analysis

13. Distance from UCFS and Poverty Rate4

14. NSR by Insurance Type

15. Insurance Provider

16. NSR by Healthcare Provider

17. NSR by Patient Age

18. CONCLUSIONS: Analysis of UCFS NSR Data Correlation… No Correlation… Distance from UCFS Poverty level of home town Patient age Healthcare provider • State/federal funded insurance providers demonstrate higher NSR

19. Results:Review of Previous Daily Appointment Records

20. Appointment Type (01/2010 - 07/2010)

21. Failed Appointments by Lag Time

22. CONCLUSIONS:Analysis of Failed Appointments • Office visits demonstrated highest NSR (37%) • Highest with lag time to appointment of 1-7 days • Failed follow-up with resolution of child’s symptoms • Follow-up from Emergency Department visits • Also, lag time to appointment of 8-14 and 30-45 days • Failed WVC occurred most frequently with lag time of 1 month and 1 year

23. Create Initiatives • Interdepartmental services at UCFS • Community Outreach Coordinator • Eastern CT Medical Home Initiative for Children & Youth with Special Health Care Needs • Literary review of current journals • Evaluate methods used to reduce NSR in other pediatric clinics http://www.ct.gov/dph/lib/dph/family_health/children_and_youth/pdf/cmhi_contractor_contact_sheet_072209.pdf

24. UCFS InterdepartmentalCollaboration • Provided insight to common socioeconomic factors impacting patient’s lives • Resource for focusing possible initiatives • CT Medical Home Initiative for Children and Youth with Special Health Care Needs • Lower NSR observed in pediatric patients already “plugged into” UCFS coordinated care services • 75% of children identified by care coordinator with low NS rates

25. Initiatives for the Future • Improve Communication • Appointment Reminders • Create consequence for negligence • Explore creation of ‘ease’ for patients • Increase use of UCFS Care Coordination/Medical Home services

26. Improve Communication Barrier to Healthcare Initiative Create “At A Glance” record in patient chart Give provider opportunity to identify and address patient with high NSR Open lines of communication to ascertain personal barriers Initiate care coordination • Personal hardships • Unique to a patient/patient’s family • Examples include: Parent/guardian work schedules, shared parenting/custodial issues, financial constraints, disinterest in compliance, lack of transportation

27. Appointment Reminders Barrier to Healthcare Initiative • Forgotten Appointments • Postcard reminders and recall telephone messages shown to increase clinic attendance for schedule appointments 2,6,8 • Frequent disconnected phone numbers and change of address • Review current automated telephone message system • Examine number of messages received by patients • Personalization vs. automated • Mailed appointment reminders • Determine practicality for a transient patient population

28. Appointment Reminders Barrier to Healthcare Initiative Modify scheduling protocol for WCV UCFS currently reviewing WCV scheduling scheduling one year WVC with shorter lag time intervals Emphasize importance of follow-up appointments Discuss patient responsibility to cancel appropriately if not following-up • Increased Lag Time • Significantly influences appointment keeping5

29. Initiate Consequence Barrier Initiative Utilization of contracts outlining consequence of NS and or failure to cancel appointments Other services within UCFS that utilized patient contracts demonstrated reduced NSR Formulate fair negotiations for pediatric population Unethical to deny care for child with high NSR Initiative must target custodian’s actions • Failure to assume responsibility for frequent NS appointments • Accountability of parent • Pediatric patient affected by parent’s/custodian’s actions

30. Create ‘Ease’ Barrier Initiative Open Access scheduling Studies have show OA may help to decrease failed appointments7 Concept already used in pediatric ambulatory clinics Extend concept to increase use of urgent care clinics Bus tickets/Care Cabs HUSKY offers this…are patients aware? • Socio-economical factors

31. Increase Use of Available UCFS Services Barrier Initiative Chart review of NS patients with high appointment number for age Identify children with special care needs Initiate coordinated care • Personal hardships • Unique to a patient/patient’s family • Case management improves receipt of preventive care3

32. Where Now? • Frequent reassessments to identify initiative and improve practice policy • Continued team work vital to achieving reduced pediatric NSR at UCFS

33. QUESTIONS? http://www.pediatrics.med.ubc.ca/Links.htm

34. References • http://www.hrsa.gov/epsdt/ • O’Brien G, Lazebnik R. Telephone call reminders and attendance in an adolescent clinic. Pediatrics 1998; 101; e6. • Hambidge SJ, Phibbs SL, et al. A stepped intervention increases well-child care and immunization rates in a disadvantaged population. Pediatrics 2009; 124; 455-464. • http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250652 • Tierney CD, Yusuf H, McMahon SR, et al. Adoption of reminder and recall messages for immunizations by pediatricians and public health clinics. Pediatrics 2003; 112(5): 1076-82. • Ross LV, Friman PC, Christophersen ER. An appointment-keeping improvement package for outpatient pediatrics: systematic replication and component analysis. J ApplBehavAnal 1993; 26(4): 461-7. • Bundy DG, Randolph GD, Murray M, et al. Open Access in primary care: Results of a North Carolina Pilot Project. Pediatrics 2005; 116; 82-87. • Irigoyen MM, Findley S, Earle B, et al. Impact of appointment reminders on vaccination coverage at an urban clinic. Pediatrics 2000; 106(4): 919-23.