How to Better Manage ‘No Show’ Appointments

“So, what should we do about 11 no-show appointments?”

Recently, a colleague brought to my attention a patient who had made and canceled multiple appointments in our practice — 11 over the 4-month span since they had been seen last, with a recommendation at that time for close follow-up to better get control on some medical conditions that had gotten out of hand.

It seems that nearly every week they were calling up, scheduling an appointment for a routine follow-up, and then calling up and “rescheduling” on the morning of the appointment. At other times, this “rescheduling” occurred after the appointment time had already come and gone.

We used to call this a broken appointment.

Apparently, if the patient reaches the call center and says they would like to reschedule the appointment, the folks there dutifully do that, even if the appointment is already technically over. They make no effort to look back into the patient’s recent scheduling history to note that this has been a pattern, an ongoing issue.

In reality, this is a waste of resources and a missed opportunity, not only for this patient’s healthcare, but for many others who are told that there is no availability on the schedule.

I know some folks who work in practices where if you are a no-show for an initial visit, you’re automatically closed out of the practice; for follow-up appointments, a pattern of more than a few no-show appointments leads to a warning letter, and then being closed out of the practice, not offered any future appointments.

The scheduling supervisors want to have strict guidelines they can enforce, a sort of “three strikes and you’re out” policy that can lead to warning letters, and if ongoing, then termination from the practice. I’ve heard lots of different arguments for the pros and cons of this, and there is never going to be a completely foolproof way to manage this.

There certainly are many reasons why patients cannot come to their appointments, often beyond their control.

I once heard of a patient who was fired from a psychiatry practice because they kept not appearing for appointments. But the reason the patient needed to see a psychiatrist was such severe agoraphobia that they kept missing chemotherapy treatments (as they were afraid to leave their house to come in for care). But other times, the reasons for missed appointments may be less extreme.

Tools can help with more effective scheduling and enforcement. For example, there is sophisticated scheduling software out there that can recognize patterns and help ensure more efficient and effective scheduling of patients.

It would be great if we did a better job of recognizing these things, and then made an effort to find out why a patient wasn’t coming, what their barriers are today and in general might be, and doing everything we can to help them overcome these. If it’s fear of leaving the house, inability to get off work, needing to care for others in the home, anxiety over taking public transportation, or whatever else it might be, we as a healthcare team should be able to explore and help.

Our goal should be to make it easy to schedule appointments, and easy for patients to keep them.

And when those situations arise, when a patient really just can’t come in — due to changing needs at home, an urgent childcare issue, or something coming up at work — then we should be able to quickly transition to telehealth options, or if that’s not feasible, then we should have a waiting list of patients ready and eager to use our services and take that appointment slot.

No one wants to overbook schedules, as this mostly just leads to chaos. But we can make sure that everyone who should be coming in does, and if they aren’t, then we should know about it as soon as possible so we can offer this time slot to someone else who might really benefit.

To help make sure patients are coming, and doing everything we can to make sure that no one falls through the cracks, we can implement: open access scheduling; frozen appointment slots for urgent visits and last-minute preoperative appointments; flexible coverage when we have an opening and our partners’ patients need to be seen; navigators who can help reach out to patients; and live people over the phone or electronic options through the portal and text messages reminding patients about appointments.

All of this can lead to a better state of health for all of our patients.

So, don’t tell me that when a patient calls at 11:30 a.m. and says they’d like to reschedule their 10 a.m. appointment that we, and the people on the phone, and the electronic systems out there, can’t figure out that this is a pattern, this is a problem, and that we can and should do something about it.

This has to be seen as a call for help, not a call to reschedule.