Date of Award

Spring 5-25-2024

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Katie Lais, DNP

Second Advisor

Joseph Burkard, DNSc, CRNA, AACN Health Policy Fellow

Abstract

Abstract

Introduction: The purpose of this evidence-based Doctor of Nursing Practice project was to implement the use of personalized text message reminders to increase adherence to out-patient psychiatric visits and decrease the rate of no-show appointments. The study site is a Southern California-based outpatient mental health practice that employs a variety of clinicians to provide mental health care to clients across the lifespan for a variety of patients throughout all socio-economic brackets.

Background: Approximately 23% of individuals who are scheduled with this provider result with a no-show appointment during the period of data mining. In general, psychiatric patients are most likely to no-show for an appointment as opposed to other outpatient specialties due to a compromised mental and emotional state that reduces drive and motivation to attend activities that would improve their current health. Many patients experiencing severe mental illness (SMI) are also lower on the socio-economic brackets and may have difficulties with transportation or maintaining service with mobile devices to meet the requirements of a telehealth visit.

For the patient, no-show appointments result in delay of receiving care which may lead to decreased access to medications. A lapse in medication adherence could potentially lead to the decompensation of symptoms which leads to a higher potential of hospitalization. If medications are used to treat substance use disorders, the lapse in medication adherence will lead to a higher potential for relapse.

For the health-care, organization, no show appointments take up appointment slots where the organizations cannot bill for that time. This results in a decreased in gross income and further delay of initial visits on a provider’s waitlist which delays reimbursement for new patients. In summation, the healthcare organization will lose reimbursement for the missed visit and delay reimbursement for a patient on the waitlist that had the potential to be seen.

Methods: The current state of the practice is evaluated to understand the current appointment reminder practice. Metrics gathered include how the reminder is generated, how far in advance the patient receives the reminder, and what the reminder will look like. The current reminder practice includes an appointment reminder that is computer generated and shows the appointment time and which provider the appointment is scheduled with. The intervention is for the provider to send out a personalized appointment reminder with a greeting and message addressing the patient by name in addition to the appointment time for the next day with the current telehealth application called Doximity. Information on how to reschedule or cancel that appointment is also provided. If a patient reschedules an appointment, it is not counted as a no-show appointment due to the potential of that appointment slot becoming taken by a back-fill patient. A back fill patient is a patient that is on the waitlist for an urgent follow up or an initial visit. The ability to fill an appointment slot with a back-fill patient allows the provider to still provide care to a patient in need, reducing the risk of adverse outcomes from a delay of care and allowing the healthcare organization to bill for the described time slot. The dependent variable is the rate of no-show appointments after the intervention. To understand the impact of the intervention, a baseline measurement of no-show appointment frequency is taken. From 12/5/2023-2/5/2023, all no-show appointments are recorded as a no-show occurrence.

Results: Initial no-show visits were at 23% average over a span of 43 days prior to intervention. After the intervention, the average no-show rate is 2.1% over a span of 37 days. This is a 20.9% decrease in the average percentage of no-show visits.

Evaluation: With an average daily patient panel of 35 patients, a 20.9% decrease in no show visits after the use of a personalized text message equates to roughly seven patients per day and 35 patients in a five day work week.

Keywords: Appointment reminders, personalized appointment reminders, appointment reminder intervals, personalized reminders, adherence, reminders, no-show.

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Available for download on Monday, May 19, 2025

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