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Client Attendance Principles and Practices: No Show , Client and Staff cancel management at the Front Desk

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Client Attendance Principles and Practices: No Show , Client and Staff cancel management at the Front Desk Presented by: Michael Flora, MBA, M.A.Ed LCPC – PowerPoint PPT presentation

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Title: Client Attendance Principles and Practices: No Show , Client and Staff cancel management at the Front Desk


1
  • Client Attendance Principles and Practices No
    Show , Client and Staff cancel management at the
    Front Desk
  • Presented by
  • Michael Flora, MBA, M.A.Ed LCPC
  • M.T.M. Services
  • E-mail michael.flora_at_mtmservices.org
  • Web Site mtmservices.org

2
  • No Shows We Must Change Our Behavior

3
Integrated Healthcare and Parity Values Needed
  • Under an Integrated Healthcare Model the
    Value of Behavioral Health Services will depend
    upon our ability to
  • Be Accessible (Fast Access to all Needed
    Services)
  • Be Efficient (Provide high Quality Services at
    Lowest Possible Cost)
  • Electronic Health Record capacity to connect with
    other providers
  • Focus on Episodic Care Needs/Bundled Payments
  • Produce Outcomes!
  • Engaged Clients and Natural Support Network
  • Help Clients Self Manage Their Wellness and
    Recovery
  • Greatly Reduce Need for Disruptive/ High Cost
    Services

4
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5
Scope of Quality Definition Reason for
Measurement
  • Accessible Services
  • Consumer-Centered Services
  • Cost-Effective Services
  • Outcome Based Services
  • Full integration of Utilization Management
  • CMS Corporate Compliance
  • HIPAA Compliance
  • State/Federal Standards
  • JCAHO/CARF/COA Accreditation Standards
  • Clinical Best Practice Performance Standards
  • Community Support Best Practice Performance
    Standards
  • Non-Clinical Best Practice Performance Standards

6
Multiple Clinician Extensive Intake Models
Exacerbates No Shows
A. Birth To Now Model
  1. Screening/Triage
  2. Intake/Admission Assessment
  3. First Appointment with Provider

B. Adequate Information Model
  1. Screening/Triage
  2. Intake/Admission Assessment
  3. Information During Treatment Process

7
Tribal Based Organizational Model Exacerbates No
Shows


A Behavioral Healthcare Organization
CA/R
A/R
DD/R
SA/D
A/DS
SA/R
CA/DS
DD/DS
A/CM
SA/IOP
CA/CM
DD/CM
A/OP
CA/OP
DD/H
SA/OP
B Adult MH
C/A MH
DD/ MR
SA/ CD
  • D
  • Fully Integrated Service Delivery
  • Single Access to Care
  • Single Assessment
  • Single Integrated Treatment Plan
  • Full Access to Continuum in all
  • Disability Programs

8
Contributing Factors to No Shows As A Result of
Loosely Held Federation Practice
  • Challenge Holding Staff Accountable
  • Quantitative documentation compliance (completion
    and timely submission). Staff need no show time
    to Catch Up Paperwork
  • Redundant Re-Work Multiple Assessment of Each
    Consumer Model
  • Standardization/consolidation of tribal based
    forms/documentation processes creates need to
    have redundant documentation model

9
No Show Documentation Solutions
  • Challenge Holding Staff Accountable
  • Move to Structured documentation (Goals,
    Objectives, Therapeutic Interventions, Outcomes)
    vs. Narrative documentation (Problem, Process,
    Methodology)
  • Closed Audit Loop Model
  • Finish Work Daily Model

10
Purpose of Assessment in Medical Necessity
Linkage Requirements
  • Establishes baseline measurement for consumers
    Symptoms, Behavior, and Skills Deficits and
    document how these impact consumers functioning
    is the basis of developing service/recovery plan
  • The more specific/objective the information
    gathering process, the easier it is to
    demonstrate the necessity for treatment
  • Standardized assessment tools (BASIS 32, GAF,
    ASI, CAFAS, etc.) used in conjunction with
    initial assessment, help establish functioning
    baseline and help justify continued necessity
  • Integrative summary of prioritized therapeutic
    needs of the consumer.

11
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12
Steps to No Show Management
  • Develop definitions of types of Initial and
    On-Going No Shows
  • Develop and implement no show performance
    standards for staff
  • Develop protocols to measure no shows as defined
  • Implement Centralized Scheduling
  • Cannot depend on consumers changing no show
    behavior staff members must change their
    behavior regarding no show activity

13
Level of Symptoms/Functioning as a No Show
Predictive Indicator
  • Current no show reduction initiatives are based
    upon the concept that a leading indicator of no
    show/cancellations is the level of symptoms a
    consumer is experiencing at the time of his/her
    appointment.
  • Therefore, if the consumer is experiencing a high
    level of symptoms, he/she will show for
    appointments due to the felt need. Likewise if a
    consumers symptom levels have subsided, then the
    consumer may feel that additional services are
    not needed at this time.
  • Utilizing this concept, the longer consumers have
    to wait for the initial intake/assessment, it
    seems that one of two things have proven will
    occur, the consumers symptoms get worse and
    he/she enters the system through emergency/crisis
    services or the consumers symptoms get better
    and he/she misses the intake/assessment.
  • Likewise, if the consumer is scheduled out for
    months in advance then staff are predicting the
    consumers level of symptoms.

14
Recommended No Show Types and Definitions
  • No Show Consumer did not call and did not
    canceled scheduled appointment for services.
  • Cancellation - Consumer called and cancelled
    appointment for service less than 24-48 hours
    before appointment and time could not be filled
    with consumer.
  • Provider Cancelled Clinician cancelled
    appointment.

15
Initial Intake No Show Performance Standards
  • Client Initial No Show Rate
  • Definition- Percentage of all client appointments
    that the client did not attend the initial
    assessment.
  • Standard-Initial No Show rate will average less
    than 25 during the last 3 months.
  • Source- Staff Activity Log
  • Compliance Rating- Initial No Show Rate less than
    25 Full Compliance
  • Initial No Show Rate more than 25
    Non-Compliance
  • Solution Plan- Provider and supervisor will meet
    within 7 days of report to develop plan to
    decrease client initial no show rate.

16
On-Going No Show Performance Standard
  • Client Ongoing No Show Rate
  • Definition- Percentage of all client appointments
    that the client did not attend after the initial
    assessment.
  • Standard- Ongoing No Show Rate will average less
    than 10 during the last 3 months.
  • Source- Staff Activity Log
  • Compliance Rating- Initial No Show Rate less than
    10 Full Compliance
  • Initial No Show Rate more than 10
    Non-Compliance
  • Solution Plan- Provider and supervisor will meet
    within 7 days of report to develop plan to
    decrease client ongoing no show rate.

17
Provider Kept Appointment Rate Performance
Standard
  • Provider Kept Appointment Rate
  • Definition - Percentage of all appointment that
    the provider did not cancel.
  • Standard - Provider kept appointment rate will
    average 90 during the last 3 months.
  • Source - Staff Activity Logs
  • Compliance Rating - Provider kept appointment
    rate 90 or above Full Compliance
  • Provider
    appointment rate less than 90 Non-Compliance
  • Solution Plan- Provider and supervisor will meet
    within 7 days of report to develop plan to
    increase providers kept appointment rate.

18
Measurement Protocols for No Show Types
  • No Shows Clinicians OR (if agency has
    centralized scheduling) Front Desk Staff code no
    shows on Event Ticket or service activity logs
  • Cancellations Clinicians OR (if agency has
    centralized scheduling) Front Desk Staff code as
    a no billable service code(s).
  • Clinician Cancelled Front desk staff maintains
    record.

19
Failure To Appear Consumer Profiles for
Intake/Assessments
  • Implement a consumer failure to appear profile
    system for use by both the Access to Care Team
    and by physicians, nurses and clinicians.
    Consumer profiles are helpful in the
    intake/admission assessment process to provide
    failure to appear accountability data.
  • A suggested standard could be that after a
    consumer fails to appear for two intake
    appointments, the third appointment would
    schedule the consumer into an intake clinic
    scheduled two times per week on Tuesday and
    Thursday (or on three days if the number of
    intake no shows merit it).
  • This process allows Urgent and Routine placements
    to be referred to the clinic within the access
    time standards allowed. Acute referrals would
    continue to be seen on an individual
    intake/admission assessment basis.
  • Some CBHOs have utilize personal computer data
    base software to enter all no shows for
    intake/assessments by first and last name and
    another identifying fact at the end of each day.
    The access unit asks all consumers who call to
    schedule an intake if they have ever visited or
    call the CBHO before. If the consumer indicates
    yes, then the database is checked to confirm if
    the consumer has missed two previous intake
    appointments.

20
Shift from Having a Schedule to Managing A
Schedule
  • Having a Schedule Model
  • Schedule Out Experience indicates that many
    clinicians schedule out appointments for several
    months when the consumer comes into services. The
    assumption is that the symptom level of
    individual consumers will maintain a sufficiently
    high level to be able to predict that the
    consumer will need services on the first and
    third Tuesdays three months from now. In this
    model it is only when the consumer does not show
    that we know. A manager can identify this model
    by reviewing the next two months schedule for
    each clinician to determine if it is Fully
    Booked.
  • Managing a Schedule Model
  • Negotiate the Next Appointment At the end of
    each appointment, the clinician discusses the
    need for a next appointment, the interval of time
    and a commitment to come. This model does not
    assume that the consumer will need services
    weeks/months in advance. Further, by completing
    the Progress Note at the end of each session, the
    clinician and consumer can discuss outcomes in
    light of a continued need to maintain the same
    frequency and intensity of services.

21
Shift from Having a Schedule to Managing A
Schedule
  • Having a Schedule Model
  • Assume Attendance In the scheduled out model
    the general assumption seems to be that the
    consumer will show. This assumption can be
    verified by asking, How many consumers are
    called before each appointment to remind them?
    A response such as, We have been talking about
    doing that provides a strong suggestion that
    staff are utilizing the have a schedule model.
  • Managing a Schedule
  • Call to Ask for Commitment A call is made to
    each consumer (who has phone service and who
    consents to the reminder calls at intake)
    approximately 36 to 48 hours prior to each
    appointment. The call can be made by support
    staff or by clinical staff if there are
    therapeutic reasons. The caller asks a very
    important question, We would like to remind you
    of your appointment with Dr. Jones on Friday at
    300 p.m., will you be able to attend, or would
    it be more convenient if I rescheduled you?
    This commitment question seems to be an important
    aspect of calling.

22
Shift from Having a Schedule to Managing A
Schedule
  • Having A Schedule
  • Let No Show Occur The traditional model of
    clinicians keeping their own appointment books
    prohibits to a large degree support staff
    managing the schedule to back file any openings
    due to no shows or late cancellations.
  • Managing A Schedule
  • Back Fill Appointments If the consumer
    indicates during the call that he/she will not be
    able to make the scheduled appointment, then a
    new appointment date and time is established and
    the support staff then calls a waiting list for
    each clinician to back fill the now open
    appointment slot.

23
Shift from Having a Schedule to Managing A
Schedule
  • Managing A Schedule
  • Move Consumer to Group Modality In most CBHOs,
    that proactively work on managing no shows, the
    standard protocol is that when a consumer does
    not show for two consecutive appointments after
    calling to remind them, they are moved to group
    modality within each clinicians case load. This
    protocol is openly discussed with consumers at
    service planning with the explanation that group
    modality can provide dynamic and inter-reactive
    peer support as well as therapy.
  • Having A Schedule
  • Keep Scheduling Consumer In many cases
    clinicians will schedule consumers at the next
    regularly scheduled time and day even though
    they know the consumer will probably not show.

24
Shift from Having a Schedule to Managing A
Schedule
  • Having A Schedule
  • Carry No Show Consumers in Case Loads At one
    CBHO, my work focused on a service utilization
    assessment for each caseload member in increments
    of 30 days (i.e., 30 days, 60 days, 90 days,
    etc.). The outcome was somewhat typical, 37 of
    the active caseloads within the CBHO had not been
    seen face-to-face for over 120 days. Clinicians
    continued to schedule these consumers as if they
    would show. Additionally, these clinicians
    expend immense amounts of energy carrying the
    paperwork requirements of maintaining an active
    chart.
  • Managing A Schedule
  • Appropriately Transfer/ Discharge Consumers If
    consumers will not show for individual and group
    modality after phone reminders, then the consumer
    is appropriately discharged. Clinicians are not
    going to spend time nor expose the organization
    to the risk of carrying caseload members for
    periods of time when they are not receiving
    services.

25
Having a Schedule Vs. Managing a Schedule Summary
  • The Having a Schedule model is very inefficient
    for the consumer, the clinician and the
    organization. Continuing to schedule consumers
    after they have given clear indication their
    symptom levels do not require additional services
    creates further dependence on the system rather
    than independence, self-monitoring, etc.
  • Obviously, consumers with SPMI needs will
    continue to need med monitoring and prescription
    services. Perhaps therapy and other non-medical
    services could really benefit from the Managing a
    Schedule Model.

26
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27
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28
Next Steps for No Show Management Development
  • Step One Define No Shows
  • Step Two Measure level of no shows
  • Step Three Develop Action Plan to address no
    shows
  • Step Four Monitor change in no
    shows/cancellations
  • Step Five Re-address Action Plan if required

29
Discussion and QA
  1. Questions and Comments?
  2. Feedback?
  3. Next Steps?

28
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