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Published in final edited form as: J Eval Clin Pract. 2023 Nov 7;30(2):243–250. doi: 10.1111/jep.13939

A formative assessment of client characteristics associated with missed appointments in integrated primary care services in rural Arizona

Jeffersson Santos 1, Carolyn Camplain 2, Amanda M Pollitt 3, Julie A Baldwin 4
PMCID: PMC11299713  NIHMSID: NIHMS1980360  PMID: 37933799

Abstract

Introduction:

Integrating primary care services in mental healthcare facilities is an uncommon model of care in the United States that could bring several benefits (e.g., improved access to physical healthcare) for vulnerable populations experiencing mental health conditions, especially those living in underserved regions like rural Arizona.

Aim:

This formative assessment aimed to understand the sociodemographic and clinical characteristics of clients accessing integrated primary care (IPC) services implemented in 2021 at a community mental healthcare facility in rural Arizona and to explore the proportion of missed appointments. Additionally, we analysed the association between client characteristics and IPC missed appointments.

Methods:

The authors collaborated with a community mental health facility in rural Arizona, which provided deidentified data from 280 clients who accessed IPC services from June 2021 to February 2022.

Results:

Most clients were White and of vulnerable socioeconomic status, with a substantial proportion of Native Americans (23.58%). The majority of clients (55.75%) had a mental health disorder (MHD), 23.74% had a substance use disorder (SUD), and 15.10% had comorbid MHD and SUD. Linear regression revealed that experiencing comorbid MHD and SUD was significantly associated with missed appointments. Compared with White clients, Native Americans missed fewer appointments.

Conclusion:

Future studies conducted from a culturally-centred perspective are crucial to guide strategies to reduce missed appointments in rural IPC services.

Keywords: delivery of healthcare, interdisciplinary health teams, mental health services, primary care

1. INTRODUCTION

Missed appointments can have significant consequences for people experiencing mental health conditions. When clients miss scheduled appointments, it disrupts the continuity of care, hindering their progress and therapeutic journey. For mental health clients, consistent support and regular sessions are essential to manage and improve their well-being.1 A missed appointment can exacerbate feelings of isolation, anxiety, and vulnerability, potentially leading to setbacks in their recovery process.2 Moreover, research indicates that missing appointments is a significant risk factor for all-cause mortality among clients with mental health conditions, highlighting the critical importance of maintaining regular attendance for optimal outcomes.3 While forgetfulness and transportation challenges are common contributors for missed appointments in mental healthcare settings in rural regions, research has found that certain sociodemographic characteristics may also play a role in missed appointments. These characteristics include race, age, sexual orientation, low socioeconomic status, homelessness, comorbidities, and type of health insurance.4

One strategy that healthcare is utilizing to improve access to care and reduce missed appointments is integrating mental health and primary care services.5 Integrated mental health and primary care is the provision of mental health and primary care services within the same healthcare facility to meet clients’ mental and physical health needs.6 Integrated care is associated with various benefits, such as improved mental and physical health outcomes, improved access to care, and improved client satisfaction.7–11 In rural regions in the United States of America (USA), efforts have been made to integrate primary care services into mental healthcare facilities to facilitate access to care for people with mental health conditions and reduce missed appointment rates.12 This is because although the most common integrated care model in the USA involves implementing mental health services in primary care facilities, research has found that people with mental health conditions are at risk for discrimination and even physical abuse from healthcare providers in nonmental healthcare settings, which plays a major role in appointment missingness among these clients.13–15 Therefore, integrating primary care services into mental healthcare facilities, known as integrated primary care (IPC), is crucial for providing regular access to primary care for underserved populations with mental health conditions who are already attending mental healthcare services.16 Nevertheless, this much-needed integrated care model is uncommon in the USA, where only 26% of the mental healthcare facilities offer IPC.17,18

Care integration in rural USA regions aims to benefit underserved populations, whether due to their socioeconomic status or racial and ethnic background. The main purpose of IPC is to promote regular access to preventive health services that benefit physical health of clients with mental health conditions; missed appointments can indicate that these clients are still not accessing the services that they need, which can lead to adverse health outcomes.4 Despite the importance of IPC for people with mental health conditions, there is limited knowledge about the functioning of IPC services in the USA and whether disparities in appointment missingness persist.19,20 Particularly, there is a need to explore the role of client characteristics associated with appointment missingness in IPC services implemented in rural regions in the USA.21,22 Evaluating missed appointments is a valuable way to identify high-risk clients, allowing healthcare facilities to develop strategies to tackle appointment missingness.23 Thus, the objective of this study was to examine the sociodemographic and clinical profile of clients accessing IPC in an underserved US region. We further aimed to determine the proportion of IPC missed appointments among these clients and the association between client characteristics and IPC missed appointments.

2. METHODS

2.1. Setting

This formative assessment was conducted at a community mental health facility situated in rural Arizona. The facility offers various mental healthcare services, such as adult outpatient mental health counselling, assertive community treatment, and residential SUD treatment. In June 2021, the facility obtained primary care service licensure from the Arizona Department of Health Services, becoming the first community mental healthcare facility to implement IPC services in rural Arizona. The IPC office is currently led by one primary care nurse practitioner (NP) who works in collaboration with the facility’s mental health providers. The IPC services are offered within the scope of practice of the NP, including health assessments, physical examinations, referrals to specialized care, prescriptions, and health education. The IPC services are provided Monday through Friday from 8 AM to 5 PM.

Rural Arizona is predominantly composed of White individuals of low socioeconomic status. In addition, 30% of the rural Arizona residents are Native Americans, as the region houses 13 federally recognized tribes, conferring the region one of the USA’s largest Native American populations.24 Rural Arizona residents are facing complex health challenges. The region grapples with a severe substance use epidemic, predominantly involving alcohol, opioids, and methamphetamine.25 Multiple rural Arizona counties report higher alcohol-related mortality rates (44.6 per 100,000 population) compared USA averages (13.1 per 100,000 population).26 Furthermore, rural Arizona records elevated age-adjusted mortality rates from substance-use related chronic conditions, such as chronic liver disease and lower respiratory disease; and from suicide, which is primarily associated with depression and substance use disorders (SUDs).25 The complex health challenges in rural Arizona are deeply associated with structural problems that have been impacting the region. The poverty averages in rural Arizona surpass those of the USA, which fuels the homelessness crisis that is impacting the region.27 In addition, rural Arizona faces a chronic shortage of healthcare services and providers across mental health and primary care. Consequently, the region has multiple healthcare deserts, making it one of the USA federally designated healthcare professional shortage areas.28 All these factors contribute to rural Arizona’s health crisis, making IPC a potential health delivery model that could improve the region’s well-being.25

Since rural Arizona has multiple healthcare deserts, which are areas without available healthcare services, the city where our community health partner is situated serves as a regional hub of healthcare resources, requiring rural Arizona residents to travel long distances to access care.25 Our community health partner is one of the few mental healthcare facilities in rural Arizona, serving around 4000 clients per year. Hence, it is essential to explore how this facility contributes to building a healthier community in a region that confronts shortages of healthcare providers and services, as well as complex health challenges.

2.2. Study design

We conducted this formative assessment in collaboration with a community mental healthcare facility in rural Arizona that implemented IPC services in 2021. This retrospective cohort study on client characteristics associated with IPC missed appointments in rural Arizona is the first of its kind. The research team has a long- standing relationship with the mental healthcare facility and was invited to conduct this study and subsequent interventions aiming to reduce missed appointments and advance care integration. The mental healthcare facility provided a data set containing deidentified electronic health record (EHR) data from clients who accessed the IPC services from June 2021 to February 2022 (8 months).

This study was guided by the Socio-Ecological Model (SEM). According to SEM, there are individual, interpersonal, community, and societal factors that can impact people’s health.29 Particularly, individual-level factors such as race, gender, housing situation, sexual orientation, and level of education play an important role in access to care and missed appointments. Also, community-level factors such as geographic location, availability of healthcare services, and quality of care are major risk factors for adverse health outcomes, as they can impact people’s ability to access care and attend appointments regularly.29 Given the unique population feature in rural Arizona and its complex community-related challenges, SEM can provide valuable guidance into the multifaceted factors influencing healthcare access and utilization in this specific context.

2.3. Quantitative data collection and analysis

Our data set contained information from 280 clients aged 18 or older. The data set included clients’ gender, age, race, housing situation, health insurance, education level, employment status, mental health diagnosis, number of scheduled appointments, and number of attended appointments.

The categories of gender were male and female. Race categories were White, Native American, and other races. Housing situation categories were homeless and not homeless. Participants living in homeless shelters at the time of the appointment were included in the homeless category. We considered education levels as a binary variable that included high school graduate and not a high school graduate as the two categories. Employment status was categorized as employed or unemployed. The mental health conditions were grouped according to diagnostic criteria and codes (e.g., depressive disorders, alcohol use disorders) from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), fifth edition.30 Also, the multiple mental health diagnoses from the data set were grouped into three main categories: whether they had a mental health disorder (MHD), SUDs, or co-occurring MHD and SUD. We calculated the number of missed appointments by subtracting the number of completed appointments from the number of scheduled appointments, information which was included in the EHRs.

We considered the number of missed appointments as a continuous outcome variable. Independent variables were mental health diagnosis (MHD, SUD, MHD + SUD, no MHD or SUD), race, age, education level, housing situation, employment status, gender, and referral source. Covariates of interest included (a) age, (b) educational attainment (not high school graduate, high school graduate), (c) housing situation (homeless, not homeless), and (d) employment (employed, unemployed).

Descriptive statistics highlighting clients’ demographic and clinical characteristics were calculated using Stata 15. Linear regression was conducted using Stata 15 to model the relationship between clients’ characteristics and number of missed appointments.31 The model was adjusted for all covariates. We report adjusted beta values, 95% confidence intervals, and p values for the associations between patient characteristics and number of missed appointments. We kept the full sample when calculating the financial piece of missed appointments, but the regression only included those with complete data (n = 180). There was no missing data on the outcome variable. Only independent variables had missing data.

3. RESULTS

3.1. Clients’ characteristics

Details about clients’ demographic characteristics, clinical profile, and referral source are shown in Table 1. The mean age of clients was 41.02 (SD = 14.25, Range = 14–74). The majority of clients were white (72.36%), male (61.65%), had stable housing (78.14%), and were unemployed (75.41%). About half of the sample had a high school degree or higher. Regarding the clinical profile of clients that accessed the IPC services, the most prevalent behavioural health condition was MHDs (55.75%), followed by SUD (23.74%), and co-occurring MHD and SUD (15.10%). The most prevalent MHDs fell into the following DSM-5-TR categories: depressive disorders (23.74%), trauma and stress-related disorders, (20.14%), schizophrenia spectrum and other psychotic disorders (17.27%), and bipolar and related disorders (12.95%). The most prevalent SUDs were alcohol use disorder (30.22%) and stimulant use disorders (7.55%). The majority of clients were self-referred (61.33%) to the IPC service, with Medicaid being the most prevalent health insurance coverage (67.63%).

Table 1.

Clients’ demographic and clinical characteristics (N = 280).

Clients’ characteristics Frequency Percentage N
Sex 279
Male 172 61.65
Female 108 38.35
Race 246
White 178 72.36
Native American 58 23.58
Other races 10 4.07
Housing status 279
Homeless 61 21.86
Not homeless 219 78.14
Employment status 244
Unemployed 184 75.41
Employed 96 24.59
Education 207
High school graduate or above 105 50.72
Less than high school 102 49.28
Behavioural health diagnosis 278
MHD 155 55.75
SUD 66 23.74
Co-occurring MHD and SUD 42 15.10
Types of MHDs
Depressive disorders 66 23.74
Trauma and stressor related disorders 56 20.14
Schizophrenia spectrum and other psychotic disorders 48 17.27
Bipolar and related disorders 36 12.95
Anxiety disorders 22 07.91
Personality disorders 7 02.52
Suicide attempt 1 00.36
Types of SUD
Alcohol use disorder 84 30.22
Stimulant use disorder 21 07.55
Opioid use disorder 11 03.96
Cannabis use disorder 9 03.24
Hallucinogen use disorder 2 00.72
Referral source 256
Self-referred 157 61.33
Court ordered 51 19.92
Care facility 38 14.84
Family 10 3.91
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Abbreviations: MHD, mental health disorder; SUD, substance use disorder.

3.2. Missed IPC appointments

Overall, there were 656 scheduled IPC appointments from June 2021 to February 2022, of which 369 (56.25%) were noncompleted appointments. Most clients (43.37%) missed one appointment. Details are provided in Table 2.

Table 2.

Missed appointments from June 2021 to February 2022.

Missed appointments Frequency Percentage
0 68 24.37
1 121 43.37
2 52 18.64
3 20 7.17
4 11 3.94
5 5 1.79
6 1 0.36
9 1 0.36
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3.3. Diagnosis, clients’ characteristics, and missed IPC appointments

Detailed results of the linear regression analysis of the association between diagnosis, client characteristics, and missed appointments are shown in Table 3. Compared with those without any mental health conditions, experiencing co-occurring SUD and MHD was significantly associated with missing 1.8 (p = 0.001) more IPC appointments than for those who did not have either diagnosis. Also, White clients missed 0.55 (p = 0.02) more appointments than Native American clients. Furthermore, linear regression results revealed no significant differences in missed appointments associated with age, educational attainment, employment status, gender, housing situation, and referral source.

Table 3.

Linear regression modelling the association between client characteristics and number of missed IPC appointments.

DV: Missed IPC appointments b SE p 95% CI
Diagnosis (ref: no SUD or MHD)
SUD −1.55 0.47 <0.001 (−2.49, −0.61)
MHD −1.45 0.44 <0.001 (−2.34, − 0.57)
SUD + MHD 1.85 0.56 <0.001 (0.73, 2.97)
Race (ref: Native American)
White 0.57 0.24 0.01 (0.10, 1.05)
Other races 0.02 0.56 0.97 (−1.09, 1.13)
Age 0.00 0.00 0.62 (−0.01, 0.01)
High school graduate (ref: less than high school) −0.11 0.20 0.55 (−0.51, 0.27)
Homeless (ref: not homeless) 0.07 0.24 0.76 (−0.40, 0.55)
Unemployed (ref: employed) 0.23 0.24 0.33 (−0.25, 0.72)
Male (ref: female) −0.08 0.20 0.69 (−0.49, 0.32)
Referral source (ref: self-referred)
Family −0.70 0.67 0.30 (−2.04, 0.63)
Court −0.04 0.26 0.86 (−0.56, 0.48)
Care facility −0.47 0.28 0.09 (−1.03, 0.08)
Intercept 2.20 0.56 <0.001 (1.08, 3.31)
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Abbreviations: MHD, mental health disorder; SUD, substance use disorder.

4. DISCUSSION

This was the first study in rural USA to evaluate the association between clients’ characteristics and IPC appointment missingness. This study described the demographic and clinical characteristics of clients accessing IPC in rural Arizona, the proportion of missed appointments, and the association between missed IPC appointments and client characteristics. We found that most clients accessing IPC were white, male, unemployed, self-referred, and Medicaid beneficiaries. In addition, many clients were Native Americans, lived in homelessness, and did not have a high school degree. Regarding the clinical profile of clients, the most prevalent SUD and MHD diagnosis were, respectively, alcohol use disorder and depressive disorders. Furthermore, we found an elevated proportion of missed appointments. About 56% of the scheduled appointments were not completed, predominantly among individuals with comorbid SUDs and MHDs. Native American clients were less likely to miss appointments compared with White clients.

Results of previous studies examining missed appointments among people with mental health conditions have been mixed. The proportion of missed appointments above 50% in our study was consistent with other studies in the literature.32–34 However, lower proportions of missed appointments in mental healthcare settings have also been found, with proportions ranging from 9.3% to 36%.34,35 Elevated proportions of missed appointments may suggest systemic-level barriers to appointment attendance.32 These barriers include child and dependent care, lack of health insurance or knowledge of affordable health insurance, and limited transportation resources.36 In particular, limited transportation resources are a major challenge for rural Arizona residents to access care. Due to the scarcity of local healthcare services, community members often find themselves compelled to undertake extensive journeys to seek care. This poses a significant challenge to attend appointments, especially in areas with limited public transportation options and a lack of affordable and reliable transportation resources. Travelling long distances to attend appointments also incurs additional indirect expenses, such as the necessity to take more unpaid time off from work for many rural Arizona residents.25 These factors result in barriers to accessing healthcare services, which can contribute to the concerning proportion of missed appointments. Clearly, the elevated proportion of missed IPC appointments in our study requires further research.

Mental health comorbidity was the strongest predictor of missed appointments in our study. Mental health comorbidity causes greater impact on clients’ cognition, which can lead to forgetfulness and reduced motivation to attend appointments.37 When not treated, comorbid mental health conditions often lead to worse outcomes than either disorder alone.38 Mental health comorbidity is also associated with adverse physical health outcomes and increased mortality. Adherence to scheduled IPC appointments is crucial for clients with mental health comorbidity since attendance is critical in facilitating appropriate treatment planning and care coordination.39 Our study suggests that clients who need IPC the most, those with mental health comorbidity, are still not getting the care they need. There are multiple promising interventions for reducing appointment missingness among people with mental health conditions, including outreach staff, distribution of video-enabled tablets for telehealth consultations, and electronic reminder systems.40–42 Although these interventions have been showing positive results, it is important to tailor strategies to decrease missed appointments according to specific populational characteristics.43 It is possible to integrate no- show prediction models into EHR systems, serving as decision support tools to identify clients at high risk of missing appointments. To mitigate this risk, appointments with a high likelihood of no-show could be double booked or, alternatively, clients with such a risk may receive more rigorous appointment reminders.44 Considering rural Arizona’s unique features, future studies are important to find points of intervention to address the appointment missingness problem.

In our study, despite the majority of clients being White, Native Americans exhibited a lower likelihood of missing appointments than their White counterparts. Native Americans have been historically marginalized from healthcare services and disproportionately experience a number of mental and physical conditions, such as SUDs and diabetes, compared with the general population.45 Most studies in the literature have reported that missed appointments are more common among Native Americans clients. For instance, a retrospective study conducted at an urban safety net health system in Baltimore involving 161,350 clients showed that Native Americans were twice as likely to miss appointments than White clients.21 Barriers to care for Native Americans encompass lack of health insurance, medical mistrust, lack of available culturally-centred care, and experiences of discrimination in healthcare settings.46 In our study, Native Americans could have missed fewer IPC appointments as a reflection of selection bias. Native Americans encounter significant challenges in accessing healthcare services, leading to differences in healthcare utilization between those who manage to assess healthcare services and those who do not. In our study, the ones who successfully overcame barriers to care and attended appointments might have better access to care compared with those who were unable to do so. As a result, this study’s findings might not accurately represent the entire population’s experiences, especially for those who face significant challenges in accessing healthcare. Future culturally-centred studies need to provide better insight regarding the perceptions of Native Americans accessing IPC at the facility. Such studies can help identify and potentialize the factors that contribute to Native Americans missing fewer appointments. In addition, such studies could inform other healthcare facilities offering IPC in USA rural communities.

Interestingly, people living in homelessness were less likely to miss appointments than those who were housed. There is a robust body of research associating homelessness with missed appointments. Factors associated with the higher likelihood of missed appointments among people living in homelessness in the USA, particularly in rural regions, include mental health comorbidity, societal exclusion and stigma, fear of being mistreated by healthcare providers, lack of health insurance, limited knowledge of available health insurance for people living in poverty, and lack of transportation.25,47 Expanding telehealth services has emerged as a strategy to promote appointment attendance among homeless populations as it helps overcome challenges such as lack of transportation. However, telehealth may pose a challenge for those who do not have access to internet.48 Another strategy to reduce missed appointments and address the health needs of people living in homelessness are partnerships between healthcare facilities and homeless shelters.49 Such a partnership with local homeless shelters has already been implemented by our community health partner. Our study suggests that people living in homelessness in rural Arizona who access IPC have improved access to care, which might not be generalizable to the entire homeless population in rural Arizona. Future studies focused on barriers and facilitators to attending IPC appointments among people living in homelessness in rural Arizona are warranted.

4.1. Limitations

The study has limitations that should be taken into account when interpreting its results. This is retrospective cohort study with a small sample size and findings were specific to a single mental healthcare facility in rural Arizona. However, this facility is one of the few mental healthcare facilities in the region offering IPC. Therefore, the findings may not be generalizable to other community mental health facilities with IPC services, however, they could be useful for future research on missed IPC appointments in rural Arizona and other underserved USA regions. This study is also limited by its reliance on EHR data.

In addition, there were two main limitations regarding the mental health facility’s EHR in the care integration process. First, the facility currently uses an EHR system that requires providers to type clients’ physical health conditions but select mental health diagnoses from a closed-ended list. Consequently, the facility could not include deidentified information on IPC clients’ physical health conditions in the data set due to its EHR interface. Because of this limitation, this project could not offer a detailed picture of the physical health conditions affecting IPC clients and whether they are associated with missed appointments.

Second, although the facility offers ongoing training on the health of LGBTQ+ people for its providers, the data set did not include clients’ sexual orientation and gender identity (SOGI) because the facility’s EHR cannot accommodate such information. Due to this limitation, we were unable to comprehend the proportion of clients who are members of the LGBTQ+ community and assess their missed appointments. The lack of data about the health status of LGBTQ+ clients is a common problem across healthcare facilities in rural Arizona and the USA.25,50 Various studies have demonstrated that, compared with heterosexuals, members of the LGBTQ+ community are disproportionately more affected by mental and physical health conditions and frequently avoid accessing healthcare services for fear of receiving poor care.51 The USA Institute of Medicine recommends the inclusion of critical social determinants of health indicators such as SOGI in EHRs.52 This will enable health systems to identify disparities in missed appointments and health outcomes among LGBTQ+ people.50 Thus, efforts should be made to include SOGI data into EHRs.

5. CONCLUSION

This study explored the proportion of missed IPC appointments at a community mental healthcare facility in rural Arizona and evaluated client characteristics associated with missed appointments. We identified an elevated proportion of IPC appointments. Comorbid mental health conditions and SUDs and White race were significantly associated with missed IPC appointments. The evidence provided in this study can be helpful to identify IPC clients at risk for missing appointments and to inform targeted strategies to reduce appointment nonattendance. We also presented several recommendations for future studies focused in IPC implemented in underserved USA regions.

ACKNOWLEDGEMENTS

This work was supported by The NARBHA Institute. In addition, this work was supported by the National Institute on Drug Abuse (NIDA) Culturally Centered Addictions Research Training (C-CART) Program (5R25DA053805-03) and the National Institute for Minority Health and Health Disparities (NIMHD) Southwest Health Equity Research Collaborative RCMI (U54MD012388).

Footnotes

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

This study was approved by Northern Arizona University’s Institutional Review Board.

Contributor Information

Jeffersson Santos, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ.

Carolyn Camplain, Department of Community and Population Health, Lehigh University, Bethlehem, PA.

Amanda M. Pollitt, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ.

Julie A. Baldwin, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ.

DATA AVAILABILITY STATEMENT

The data that support the findings of the current study are available from the corresponding author on request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of the current study are available from the corresponding author on request.

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