A multi-method intervention to reduce no-shows in an urban residency clinic.

BACKGROUND AND OBJECTIVES Missed appointments can create financial, capacity, and continuity issues in primary care. An urban family medicine residency teaching clinic with a large culturally diverse population of low-income patients struggled for decades with a persistent no-show rate of 15%--17% despite multiple attempts to remind patients or otherwise address the problem. This study sought to measure the effects of a multi-method approach to decreasing the overall clinic no-show rate over time. METHODS A team of clinicians and staff undertook a systematic review of the literature to identify an approach to decreasing the number of no-show appointments while maintaining a commitment to the population and quality of care. The team implemented a three-stage process: an interview with the cohort of patients with the highest number of repeated no-show appointments, a double booking process for patients with a history of frequent missed appointments, and a change in the entire schedule to a modified advanced access schedule. RESULTS A cohort of 141 patients (2% of the practice population) accounted for almost 17% of the total missed appointments. The cohort differed from the overall clinic, being largely African American women on Medicaid with a large burden of medical comorbidities and a high prevalence of mental health issues. After the intervention, the rate of no-show appointments in the cohort fell from 33.3% to 17.7%, and the overall clinic rate fell from 10% to 7%; this decrease persisted for the 33-month observation period after the intervention and has been maintained to this date. The largest improvement in appointment keeping came after a modified advanced access schedule was implemented clinic-wide. CONCLUSIONS Indentifying a large at-risk population for no-shows and using a multi-method approach to addressing the issue can show persistent improvement and could be used in other residency training and community clinic settings.