Did Not Keep Appointment DNKA Can You Lower

Did Not Keep Appointment (DNKA): Can You Lower Your Rate? Carin E. Reust, MD, MSPH Associate Professor Department of Family and Community Medicine Columbia MO

Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

Learning objectives: 1. Identify potential causes for a “Did Not Keep Appointment” (DNKA) 2. Identify and utilize tools to study the DNKA rate within a practice. 3. Discuss methods that lower the DNKA rate.

DNKA Rate at 8 FM Clinics FCM DNKA % by Location 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Jun, 2009 Jul, 2009 Aug, Sep, Oct, 2009 R 2 Nov, Dec, Jan, 2009 2010 W Feb, Mar, Apr, 2010 R 1 May, Jun, 2010 R 3 Jul, 2010 E Aug, Sep, Oct, 2010 P 1 Nov, Dec, Jan, 2010 2011 P 3 Feb, Mar, Apr, 2011 P 2 May, 2011

DNKA Rate at 8 Family Medicine Clinics 16 14 West DNKA RATE % 12 East 10 P 1 8 P 2 6 P 3 4 R 1 2 R 2 0 R 3 2008 2009 2010 2011 Fiscal Year 2012 Fiscal year 2012: 2681 patients $227, 700

DNKA Rate at 8 Family Medicine Clinics 16 14 DNKA RATE % 12 10 8 West 6 East 4 2 0 2008 2009 2010 2011 Fiscal Year 2012 Fiscal year 2012: 2681 patients $227, 700

DNKA Rate at 8 Family Medicine Clinics 14 DNKA RATE % 12 10 8 P 1 6 P 2 P 3 4 2 0 2008 2009 2010 2011 Fiscal Year 2012 Fiscal year 2012: 2681 patients $227, 700

DNKA Rate at 8 Family Medicine Clinics 16 14 DNKA RATE % 12 10 8 R 1 6 R 2 R 3 4 2 0 2008 2009 2010 2011 Fiscal Year 2012 Fiscal year 2012: 2681 patients $227, 700

How often do people DNKA? • • Pediatric Allergy Clinic - 33% Postpartum Clinic - 73% High Risk OB Clinic - 28% Derm Clinic - 17% Specialist Clinic – 38% Vascular Lab - 12% Colonoscopy - 21% (Dreiher 2008) (Smith 1990) (Campbell 2000) (Penneys 1999) (Dosse 2009) (Satiani 2009) (Corfield 2008)

How often do people DNKA? • UK: Four Primary Care Clinics (Neal 2001) – Range: 4. 2%, 4. 7%, 10. 0%, 11. 8% • Urban FM residency clinic (Smith 1994) – DNKA Rate 26% • FM residency survey (Johnson 2007) – DNKA Range 3 -42%, mean 17%, median 15%

Patient Characteristics • • • Age Ethnicity Socioeconomic Status Insurance History of Missing Appointments Perceived Need for Appointment

Practice Characteristics • • • Access Time to Appointment Referral Source Attitude toward patients Clinical Efficiency “What’s up with Nurse Triage? ”

Random Characteristics • • Is it a Monday or a Friday? Is it a morning or afternoon? Is the weather nice? Or really bad? Travel time?

Our QI Team • • 3 Front office 3 Nurses 2 Physicians 2 Admin • Monthly meeting • September 2010 -2011

Strategies and Tools • Practice Issues • Tools • LOT Strategies

Practice Issues • DNKA letters – Everyone doing something different • Patient education – Not doing anything about it • • Cancelling upcoming appointments Problem patients Reminding patients of appointments Physicians not connected to the process

Practice Issues - DNKA Letters • Readable? Appreciate the issue? – Initially reading level of 10. 5, redone to 6. 6 • A new patient v. established patient – Not keeping appointment with the clinic, rather than a provider • DNKA 1, 2, and 3 letters DNKA 1 – nice letter DNKA 2 - outline the issue; send certified DNKA 3 - terminated

DNKA 2 , certified (through 6/12) • 43 DNKA 2 Certified letters – 74% refused • Age 14% Accepted – 49% age 31 -50 14% < 3 years old – 25% age 18 -30 12% > 50 years old • Diagnosis – 16% with psychiatric issue – 7% substance abuse – 5% with pain issue • New patients – 4 – never came

6 Accepted DNKA letter • 2 were new patients – 1 called to get nursing advise, given advise – 1 called to explain no copay, self-insured • 4 established patients – 1 transferred care to OB, gyn, ER – 6 visits, 2 DNKAs – 3 visits, 1 DNKA – 1 no appt since, MRI in system

DNKA 2 Certified Letters • In this group, a 40% DNKA rate after letter • 3 transferred , outside of system • 1 transferred within the clinic – 13 visits, 4 DNKAs • 2 transferred to another FM clinic – 8 visits, 8 DNKAs; 10 visits, 4 DNKA • 1 – “no narcotics if you don’t come” – 8 visits, 1 DNKA

Problem Patients • “Some patients just don’t respond to anything. ” – (Clearly a practice not patient centered issue) • Contract with patients: – Have them confirm appointments • or, Contract with patients: – To see them when they call

Over the last few months, you have missed many appointments. When you do not keep your appointments, your doctor can not provide good care to you. Also, others patients who are sick cannot be seen during your appointment time. We can discharge you from our clinic. However, I would like to continue to provide you with medical care. If you make an appointment, you must call the day before to say you are coming to the appointment. If the appointment is not confirmed, the appointment will be cancelled. Your doctor will not be able to provide you medical care that day. In order to confirm your appointment, you will need to call our clinic. Our phone number is (zzz)xxx-yyyy. Please ask the front office to document in your chart that you called to confirm the appointment so that we do not cancel your appointment. You must call to confirm your appointment the day before, or it will be cancelled.

One “Problematic “ Patient • • Placed on contract after 9 DNKAs Made 3 appointments DNKA 5 appointments after confirming Since discharge from practice: – 7 ER visits – 2 psych visits – 1 ortho visit

Practice Issues • Patient Education – Mailing to our practice – Include letter with our new patient information – Educate them

Since opening in 2008, XYZ Clinic has grown into a successful and thriving clinic; and we thank you, our patients, for making that happen. During this period we realize some of you have not gotten in to see your physician as quickly as you would have liked. We have a few suggestions that might help with this. If you make an appointment please be sure to keep it. If you cannot keep your appointment, please call our office as soon as possible to cancel that appointment. We prefer that you cancel your appointment 24 hours prior to your scheduled appointment. We realize you may not always have 24 hours advance notice, but please make an effort to call as soon as possible. Cancelling promptly gives other patients an opportunity to be seen in your place. Again we want to thank you for trusting us with your care and the care of your loved ones and for the many referrals of your friends and family. Sincerely, Smiley Lane Family Medicine Staff

ARE YOU A DNKAer? A DNKAer is someone who schedules a doctor’s appointment and then doesn’t keep it. At Smiley Clinic, on average, 11% of our appointments are not kept by a DNKAer. One way physicians work with this issue is to overbook their schedule. That way when people don’t come, we can see someone else. Another approach is to kick people out of a practice when they do this a lot. I don’t particularly like either one of these approaches. However, it is very frustrating to try and take care of people who don’t come and even more frustrating to give people appointments for another day when we could have seen them that day. What can you do? Keep your appointments – don’t be a DNKAer! If you can’t keep your appointments, call as early as possible so we can schedule someone else

Practice Issues • Cancelling upcoming appointments – Patient seen and told to follow-up in 3 months. – Then is seen in 2 months and told to come back in 3 months; now has appointment in 1 month and in 4 months – Front office not appreciating this • Print out if 1 upcoming appointment , given to nurse-physician team to address

Reminding patients of Appointment • Automatic reminder – Doesn’t work • Personal reminder – 2 unit patients and Procedures – All

Physician Issues • Don’t care or do care? – A relief or a frustration • What is my DNKA rate? • Disconnected with processes in clinic – “Obviously they should have cancelled next appointment” – “When people are called what do they say? ” – So what are we doing?

What am I suppose to do? ALL: check visit list/IDX to see if patient future appointments aren’t necessary Front office: Contacting all appointments the day before appointment. Generating a DNKA note to physician that includes who contacted patient day prior and what they said; also send note to nursing. For our Chronic DNKAer, checking IDX comment box, reminding patient of the policy ; when they call to confirm, documenting in PC and sending to nursing Nursing staff: Calling procedures the day before Calling patients who get a certified DNKA 2 letter sent to them Maintain list of Chronic DNKAers in the pod Physician staff Sending DNKA letters to new patients Sending more DNKA 2 letters, certified or not Placing patients on contract for chronic DNKAer behavior Reviewing their monthly DNKA rate.

Tools • Run charts and Swim Lanes

DNKA Clinic B report date: March 9, 2012 20. 0 18. 0 16. 0 14. 0 12. 6 12. 3 12. 0 11. 1 10. 9 10. 0 9. 4 9. 1 8. 4 8. 0 11. 7 11. 6 10. 8 12. 3 11. 0 10. 5 9. 7 10. 1 10. 6 10. 0 9. 2 9. 1 8. 7 8. 1 8. 0 8. 3 9. 7 9. 4 8. 1 6. 9 6. 0 4. 0 2. 0 Au Jun -20 09 g-2 00 9 Oc t-2 00 9 De c-2 00 9 Feb -20 10 Ap r-2 01 0 Jun -20 10 Au g-2 01 0 Oc t-2 01 0 De c-2 01 0 Feb -20 11 Ap r-2 01 1 Jun -20 11 Au g-2 01 1 Oc t-2 01 1 De c-2 01 1 0. 0 9. 0

Length of Time to Appointment 60 50 Percent 40 30 New Established 20 10 0 Same Day 1 -5 days 6 -10 days 11 -30 day 31 -60 > 60 days October 2010 - March 2011

Same Day Appointments: 3 -6% DNKA Rate

Length of Time to Appointment 60 50 Percent 40 30 New 20 Established 10 0 Same Day 1 -5 days 6 -10 days 11 -30 day 31 -60 > 60 days Length of Time to Appointment October 2010 - March 2011

LOT strategies • For New patients: – Appointment within 14 days or no appointment • For established patients: – If seen, uncertain if needs appointment in couple days, have them call in couple days and work-in – Emphasize why follow-up appointment is being made

What Worked? • DNKA letters, signage and cancelling upcoming appointments – no direct measure of this • Problematic Contract – used once • DNKA certified letters – they aren’t picked up • Info to nurse-physician teams: turns out we are a little bit competitive

What Worked? • Contacting Patient prior to appointment Seems to help quite a bit. DNKA rate increases when we are short staffed in the front office by ~ 10% This is physician variable.

What worked? • Run Charts - helped us keep track of where we were at and if things were helping. Highlighted variability No pat on the back a month at a time Physicians respond well to data

DNKA Clinic B report date: March 9, 2012 20. 0 18. 0 16. 0 14. 0 12. 6 12. 3 12. 0 11. 1 10. 9 10. 0 9. 4 9. 1 8. 4 8. 0 11. 7 11. 6 10. 8 12. 3 11. 0 10. 5 9. 7 10. 1 10. 6 10. 0 9. 2 9. 1 8. 7 8. 1 8. 0 8. 3 9. 7 9. 4 8. 1 6. 9 6. 0 4. 0 2. 0 Au Jun -20 09 g-2 00 9 Oc t-2 00 9 De c-2 00 9 Feb -20 10 Ap r-2 01 0 Jun -20 10 Au g-2 01 0 Oc t-2 01 0 De c-2 01 0 Feb -20 11 Ap r-2 01 1 Jun -20 11 Au g-2 01 1 Oc t-2 01 1 De c-2 01 1 0. 0 9. 0

What Worked? • Swim lanes - Staff respond better to visual information rather than written information “What was I supposed to do in this situation”

What Worked: LOT strategies • Same day, no strategy • New patients within 14 days or no appointment

Clinic B New DNKA/new pts % 40 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Clinic B New DNKA/total pts % 2. 5 2 1. 5 1 0. 5 0 0 2 4 6 8 10 12 14 16

Clinic B Return DNKA/return pt % 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Clinic B Return DNKA/total pts % 14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 14 16

What Worked: LOT strategies for Established Patients • Days 1 -5: rechecks worked in • Day 6 -10: nothing

DNKA Rate 16 14 12 10 d 1 -5 8 d 6 -10 6 4 2 0 0 2 4 6 8 10 12 14 16

What Worked: LOT strategies for Established Patients • Days 11 -30: Do patients know why they are coming back? • Days >31: DNKA letters, signage

DNKA Rate 25 20 15 d 11 -30 d 31 -60 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

LOT – what worked • Limiting new patients to appointment in 14 days or no appointment • It would appear Established patients with appointments > 31 days did better (practice issues – signage, cancelling upcoming appointments? )

What Could Improve DNKA rate? • Text messages • Incentives • Reminder (Koshy 2008; da Costa 2010; Taylor 2012) (Smith 1990; Baren 2006; Powers 2009) (Swenson 1988; Campbell 1994; Moser 1994) • Confirm appointment (Tanka 1994, 1997; Reda 2001; Sawyer 2002; Tayal 2006; Haynes 2006; Corfield 2008; Satiani 2009) (Buckley 1990; Jones 1990; Turner 2008) • Connection in person • Complete something before appointment scheduled • Open Access (Macqueen 2002) (Kennedy 2003; Bundy 2005; Bennett 2009)

What Helps Improve Rate? • 47% willing to pay a booking fee, refunded if appointment kept. (EURO 20) • 52% okay with appointment buddy – reminder sent to friend or relative (Roberts 2011)

Comparison of Two Clinics Clinic A • • • Opened 1975 Resident/Faculty Site Rural Population 13, 000 4 Physicians, 8 Residents, 1 Fellow, 1 Nurse specialist • 16, 293 visits last year Clinic B Opened 2008 Faculty Site City Population 110, 000 6 physicians, 1 Fellow, 1 Researcher, 1 Nurse Specialist • 15, 578 visits last year • • •

DNKA Run chart – Clinic A and B March 9, 2012 20. 0 15. 5 16. 0 15. 4 14. 6 14. 2 14. 0 12. 2 12. 3 12. 0 10. 0 Call All 17. 5 17. 4 18. 0 13. 3 12. 6 12. 4 11. 7 9. 4 11. 1 11. 6 11. 4 10. 9 10. 8 9. 1 8. 4 13. 7 13. 6 11. 7 10. 8 14. 5 14. 3 16. 0 15. 9 14. 8 14. 5 12. 3 14. 0 12. 7 12. 3 11. 0 10. 5 9. 7 11. 8 10. 1 10. 0 9. 8 9. 1 8. 7 8. 0 11. 3 10. 7 10. 6 11. 1 8. 0 9. 6 9. 7 8. 3 9. 4 9. 2 9. 8 9. 0 8. 1 6. 9 6. 0 4. 0 2. 0 Start Call All New Pt Freeze Stop Jun -20 09 Jul -20 09 Au g-2 00 9 Sep -20 09 Oc t-2 00 9 No v-2 00 9 De c-2 00 9 Jan -20 10 Feb -20 Ma 10 r-2 01 0 Ap r-2 01 0 Ma y-2 01 0 Jun -20 10 Jul -20 10 Au g-2 01 0 Sep -20 10 Oc t-2 01 0 No v-2 01 0 De c-2 01 0 Jan -20 11 Feb -20 Ma 11 r-2 01 1 Ap r-2 01 1 Ma y-2 01 1 Jun -20 11 Jul -20 11 Au g-2 01 1 Sep -20 11 Oc t-2 01 1 No v-2 01 1 De c-2 01 1 Jan -20 12 0. 0

Clinic A –LOT and DNKA Rate 30 25 20 same day, 15 d 6 -10 d 1 -5 d 11 -30 10 d 31 -60 d>60 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Clinic B – LOT and DNKA Rate 25 20 same day, 15 d 1 -5 d 6 -10 d 11 -30 10 d 31 -60 d>60 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

New DNKA/New Patients (%) Clinic A Clinic B - CQI 40 35 30 30 25 25 20 20 15 15 10 10 5 5 0 0 0 5 10 15

New DNKA/ Total Patients (%) Clinic A Clinic B – CQI 2. 5 2 2 1. 5 1 1 0. 5 0 0 1 2 3 4 5 6 7 8 9 1011121314 0 5 10 15

Return DNKA/Return Patients (%) Clinic A Clinic B -Intervention 18 16 14 14 12 12 10 10 8 8 6 6 4 4 2 2 0 0 0 5 10 15

Return DNKA/Total Patients (%) Clinic A Clinic B -CQI 16 14 14 12 12 10 10 8 8 6 6 4 4 2 2 0 0 0 5 10 15

Rate Exemplars, Practices (Johnson 2007) • Patient education • Patient Reminders – DNKA rate doubled when reminder calls stopped • Sanctions – 90% dismissed from practice • Open Access – DNKA rate dropped to 4% • Emphasis on continuity • Scheduling rules

Physician Effect 20 18 16 Percent 14 12 2009 10 2010 8 2011 6 4 2 0 Doc A Doc B Doc C Doc D Doc E Doc F

7/09 -9/11 60 50 40 A 30 B 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

10/08 -9/11 35 30 25 20 A 15 B 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

10/08 -9/11 30 25 20 1 2 15 3 10 4 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

10/08 -9/11 30 25 20 15 4 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

20 DNKA Rate 2 Clinics, June 2009 - October 2012 18 16 12 10 Clinic A 8 Clinic B 6 4 2 0 June Aug Oct Dec Feb Apr Jun Aug Oct DNKA Rate % 14 Months

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