How many times do you let patients miss appointments before discharging them?

[SpongeBob DoctorPants]

Our clinic has a policy of discharging patients who have failed to show for 3 appointments within 12 months, but the decision ultimately rests with the treating provider. It is frustrating when patients don't show; not only does it affect their care but it also affects me personally in terms of lost income/RVUs. However, I tend to be forgiving and give people extra chances, and I believe I tend to be more forgiving for my pediatric patients, because it's technically not their fault for the missed visit and I care about my patients' well-being. I again met with frustration this week, when I had a patient who no showed yet again, after I had already given them an extra chance. (This actually is the patient's 4th no show in 12 months, and their 3rd in the past 2 months.) The father called an hour after the appointment to apologize and said he'd been busy and forgot to set the alarm so they didn't wake up in time. This patient has missed appointments with other providers in our clinic before, as well, but I have been seeing this patient for about a year, and generally they have been good about keeping appointments but for some reason have been terrible recently. Objectively I feel like discharge is appropriate, but I also don't want to do that for the patient's sake. I'm venting here but I'm also wondering how others handle recurrent no shows.

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[LadyHalcyon]

Our clinic has a policy of discharging patients who have failed to show for 3 appointments within 12 months, but the decision ultimately rests with the treating provider. I tend to be forgiving and let patients reschedule. It is frustrating when patients don't show; not only does it affect their care but it also affects me personally in terms of lost income/RVUs. I tend to give people extra chances when they hit their 3rd no show, and I believe I tend to be more forgiving for my pediatric patients, because it's technically not their fault for the missed visit and I care about my patients' well-being. I again met with frustration this week, when I had a patient who no showed yet again, after I had already given them an extra chance. (This actually is the patient's 4th no show in 12 months, and their 3rd in the past 2 months.) The father called an hour after the appointment to apologize and said he'd been busy and forgot to set the alarm so they didn't wake up in time. This patient has missed appointments with other providers in our clinic before, as well, but I have been seeing this patient for about a year, and generally they have been good about keeping appointments but for some reason have been terrible recently. Objectively I feel like discharge is appropriate, but I also don't want to do that for the patient's sake. I'm venting here but I'm also wondering how others handle recurrent no shows.

It has really depended on the setting for me. Currently I work in a pretty laid back private practice. The person loses their "regular" spot after 2 no-shows. I also keep about 4 open spots during the week for current clients if they have to reschedule etc. I typically have no problem seeing people who have a history of no-shows if they can slide into one of those spots. That being said, if it is a chronic problem and I think it has to do with lack of engagement in therapy or substance use etc, I will send them a 30-day letter saying they have to schedule AND be seen within 30 days or they will be discharged.

 

[romanticscience]

I have a late/now-show fee. The fee is waived annually or if the patient re-schedules within the week. I expect patients to re-schedule themselves because they don't have standing appointments. Usually, people will exhaust their waiver and then incur the fee. At that point, there is only a weak alliance with them, and they ultimately get discharged (they don't pay the fee). If a very reliable patient goes past 1-annual no show or late cancel, I usually let it slide.

 

[FlowRate]

I feel like we had a thread on this recently.

I'm currently in residency and we're pretty well isolated from the financial considerations.

If someone needs to be engaged in MH treatment, they basically get to continue no-showing and late-canceling appointments as long as they make some of them or don't take up too much of my schedule. This is a rather small fraction of the patient population. Severe BPD with medical comorbidities and BPAD generally.

For most other patients, three no-shows within a year and you're out. First one is a "sorry we missed you, please reschedule" letter. Second one is "I have to see you in 30 days to keep giving you meds." Third is "sorry, will send one last fill of meds the one month (if appropriate), let us know if you need help finding a new psychiatrist."

 

[wolfvgang22]

In contrast, the VA allows infinite no shows. When a patient no shows an appointment, we are directed to call them three separate times, and also try their emergency contact number. The VA simultaneously sends a letter from California or somewhere. If the veteran shows up later at anytime, someone has to see him or her the same day as a walk in. This of course is problematic from a perspective that values autonomy and patient ownership and engagement in the recovery process.

At the VA, I'm surprised they haven't asked me to personally pick up the patients on the way to clinic in the morning and face disciplinary action if less than 98% show up. We already have nurses and receptionists calling them the day before their appointment, in addition to a postcard sent prior. It's like a Jerry Lewis telethon. Even so, we have a 9% to 12% no show rate here at my facility.

 

[WisNeuro]

Even so, we have a 9% to 12% no show rate here at my facility.

That's pretty low compared to my MH unit when I was with the VA at my last job, we sat at about 20% Hooray patient accountability!

 

[birchswing]

In contrast, the VA allows infinite no shows. When a patient no shows an appointment, we are directed to call them three separate times, and also try their emergency contact number. The VA simultaneously sends a letter from California or somewhere. If the veteran shows up later at anytime, someone has to see him or her the same day as a walk in. This of course is problematic from a perspective that values autonomy and patient ownership and engagement in the recovery process.

At the VA, I'm surprised they haven't asked me to personally pick up the patients on the way to clinic in the morning and face disciplinary action if less than 98% show up. We already have nurses and receptionists calling them the day before their appointment, in addition to a postcard sent prior. It's like a Jerry Lewis telethon. Even so, we have a 9% to 12% no show rate here at my facility.

I remember watching a documentary on school truancy. I forget which area it was, but it was economically poor. And they had a team of people driving around to students' houses or finding them on the streets and entreating them to come to school. It was not at all punitive. It was very much like these administrators were pleading with students to come. Not saying it's bad. Just reminded me of your image of driving patients to the clinic.

When I volunteered at an adult reading center in college, we had a year long project in which we had to identify the greatest barriers to people coming to the center and then propose a grant for the best way to spend their budget to bring more people in. I remember lots of door-to-door surveys, can't remember what happened in the middle, but the end result was that we proposed they buy a van to pick people up to get to the center.

I'm guessing the VA probably already has transportation services like Medicaid though? Medicaid does have transportation services I found out; although, I don't know if a lot of people would know about them.

 

[Stagg737]

Our clinic has a policy of discharging patients who have failed to show for 3 appointments within 12 months, but the decision ultimately rests with the treating provider. It is frustrating when patients don't show; not only does it affect their care but it also affects me personally in terms of lost income/RVUs. However, I tend to be forgiving and give people extra chances, and I believe I tend to be more forgiving for my pediatric patients, because it's technically not their fault for the missed visit and I care about my patients' well-being. I again met with frustration this week, when I had a patient who no showed yet again, after I had already given them an extra chance. (This actually is the patient's 4th no show in 12 months, and their 3rd in the past 2 months.) The father called an hour after the appointment to apologize and said he'd been busy and forgot to set the alarm so they didn't wake up in time. This patient has missed appointments with other providers in our clinic before, as well, but I have been seeing this patient for about a year, and generally they have been good about keeping appointments but for some reason have been terrible recently. Objectively I feel like discharge is appropriate, but I also don't want to do that for the patient's sake. I'm venting here but I'm also wondering how others handle recurrent no shows.

One of my attendings PP's had one morning per week that was a walk-in clinic from 8am to 11am (as in if you show up during those times you'll get seen that day). Their policy was that after X no shows patients could only be seen through the walk-in clinic until they showed up consistently for a certain period of time and the docs were willing to take them back (rarely happened as those patients couldn't show up consistently). Was a pretty effective method as the vast majority of his patients showed up and were actually on time (and almost none were the worried well).

 

[TexasPhysician]

It depends on the setting.

In my private practice, a no-show pays the full fee. They can no-show weekly, and it doesn’t effect my finances.

I’ve worked elsewhere in which it was highly agitating that the no-show policy was so relaxed that it effected my pay. I elected to double-book an already busy schedule just to ensure I got paid. Ended up quitting that job mainly due to this frustration.

 

[GEToutLADYits6AM]

It depends on the setting.

In my private practice, a no-show pays the full fee. They can no-show weekly, and it doesn’t effect my finances.

I’ve worked elsewhere in which it was highly agitating that the no-show policy was so relaxed that it effected my pay. I elected to double-book an already busy schedule just to ensure I got paid. Ended up quitting that job mainly due to this frustration.

If they don't show up, what makes you think they going to pay you cash?

 

[VA Hopeful Dr]

If they don't show up, what makes you think they going to pay you cash?

Because you refuse to schedule another appointment until they do and its not like its easy to find another psychiatrist in most places.

 

[TexasPhysician]

If they don't show up, what makes you think they going to pay you cash?

Credit card is on file and I have a signed consent to bill it.

 

[whopper]

Instead of "termination" you could just say they're not allowed to schedule again until they pay the no show fee.

I have a patient who frequently no shows but he always pays the no show fee. So heck I'll keep him.