A Call Worth Making

Could something this simple really work?

At a recent meeting about practice management, while discussing ways to improve access, we dove once again into our usually high, very troublesome no-show rate -- the fact that many of our patients break appointments.

Everything we've been trying to do to try and get patients urgent and same-day access, like sick visits or those being sent home from the emergency room or the inpatient services, has been frustrated by the lack of available appointment times.

We've created bump lists, added people to work on shuffling and reshuffling the schedules, created "frozen" appointments that "thaw" 24 and 48 hours in advance, and built other reserved appointments for same-day, rapid discharge, and walk-in patients.

Overbooking -- we've tried that. Usually this just leads to three patients showing up at the same time, and then everyone's upset.

But still, our no-show rate has remained incredibly high, ranging upwards of 40% at times.

Of course, we get pressure from the powers that be, insisting that we make access for the emergency department and inpatient discharges that need to be seen, and our own established patients continue to complain that they're unable to get in to see us.

And that high no-show rate leads to decreased volume, which leads to decreased billing, which leads to decreased revenue, which makes those same people (and many others) unhappy.

As we were going through the problem, trying to analyze how we could improve things, we kept noticing that our highest no-show rate was for initial visits -- new patients who schedule appointments to come to establish care here. This includes new patients being referred from the hospital, as well as those who just found us through the Internet or referrals from friends or family.

In our practice model, there's no skin off anyone's teeth if you don't show up for an appointment, beyond the fact that you are not getting healthcare that you probably need.

In the old days, and in the present day for some practitioners, if you don't show up for an appointment, you got charged for that appointment. It's not a bad business model, and many doctors and other businesses still work this way, out of necessity.

However, most of our insurance contracts do not allow for any punitive charges for no-shows.

When we have tried to talk about this with patients, they say they schedule an appointment to come here for care, but then decide to see another doctor, and getting in touch with us was a challenge. Or else their schedules changed and they were unable to keep that appointment. Or else their dog ate their homework.

Quickly pulling up our schedule and running through the appointments for the previous few weeks, we saw we were seeing several hundred patients a day, and averaging somewhere between 40 and 50 initial visits per day. Our no-show rate for these initial visits was hovering between 30% and 40% just over this time course.

So we decided to try something. Why not invest in a simple phone call the night before to new patients, to remind them that they had an appointment with us to establish primary care, and ask them if they're going to keep the appointment or wished to reschedule?

Yesterday we had 40 initial visits scheduled -- 19 with attendings and 21 with residents. Those phone calls allowed us to confirm 17 appointments, for 13 people we left messages on their voicemail, five had either a full voicemail or an inactive phone number, but interestingly five patients canceled on the basis of that phone call.

So what happened yesterday, of those 35 patients that were left on the schedule, there were only seven who did not show up. This dropped our no-show rate from approximately 35% to 21%. With nothing more than a simple phone call the night before.

And if we consider the 17 reached and 13 messaged (total 30) leading to 28 kept appointments (best case scenario), then this could be viewed as a 93% effective intervention.

But best of all, most importantly, this freed up time, space on the schedule, places for registrars to put a walk-in patient or patient who'd been told a few days earlier that there were no available appointment slots.

Suddenly were able to take care of a few more of our patients that really needed to be seen. Each of those initial visits that were removed from the schedule in advance opened up at minimum two subsequent visit appointment slots.

We've tried sending out postcards in advance, we have a Robo-caller that 48 hours before asks patients to push a button selecting number 1 if they want to keep their appointment or number 2 if they want to cancel or number 3 if they want to reschedule, but in reality we've seen that these things really weren't moving the dial all that much.

This simple phone call, that simple request, to do us the courtesy of telling us whether you're coming, seems to have done more than we could have imagined.

Now, it's probably too onerous to do this for all of the 200 to 300 patients on our schedule every day, but since these initial visits are more of a problem, are longer, and getting them cleaned up frees up a lot of available time slots, it may be worth the ongoing investment.

We're going to continue this project, this mini-pilot, and then drill even deeper, looking to see who and what types of appointments are being canceled, who is not showing up, and who is keeping their appointments. Are there characteristics that we can identify that might help us predict which are the best appointments to try and confirm? Are those appointments made less than 48 hours before the scheduled time more likely to be kept, or more likely to be broken? If the patient is traveling from far away are they more likely to come, or more likely to break the appointment?

But at least for now, seems like a phone call from us getting you to commit to whether you're coming or not seems to really make a difference. Maybe it's the personal touch, maybe they think, "Wow, this practice really cares about me," and maybe that makes it all worthwhile.

Worth the call.

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A Call Worth Making