Reframing “No-Show”: Patient-Reported Barriers for Missed Post-Hospital Discharge Primary Care Follow-Up Visits

Abstract

Post-hospital discharge primary care follow-up may reduce readmissions. Missed appointments without cancellation, “no-show” visits, may cause missed patient care and system inefficiencies. There is limited research on patient perspectives of barriers to successful completion of post-discharge primary care follow-up visits. In a quality improvement process over 6 weeks, care coordinators called adult patients (N = 36) who had a missed post-discharge primary care follow-up visit with a primary care physician in an academic health system. Of 22 (61%) patients reached, categories of patient-reported barriers were: (1) missed communication opportunities (n = 15) (eg, patient did not know visit was scheduled, did not feel the need to see primary care physician, or forgot); (2) access difficulties (n = 7); and (3) family or work-related issues (n = 2). Most patients completed the rescheduled visit. Continued quality improvement efforts to improve post-discharge primary care follow-up should consider reframing “no-show” visits to address communication and access barriers at the health system level.

Introduction

Of approximately 25 million US adult hospitalizations annually,¹ the 30-day all-cause hospital readmission rate is approximately 14%.² Timely post-hospital discharge (post-discharge) primary care follow-up may reduce readmissions through assessing patients’ recovery, counseling on medications and self-management, and adjusting treatment plans and coordinating specialty care as needed.^3–7 Missed appointments without cancellation, “no-show” visits, may lead to delayed or missed patient care and system inefficiencies as unused appointment slots that could have been accessed by other patients needing care.⁸ Missed primary care visits vary from approximately 10% to more than 40% by practice setting;^3,9–14 for example, 16% in a community health center¹⁰ and 27% in a large health system.¹² Few studies have specifically examined post-discharge primary care visit “no-show” rates.^3,13,14

Prior research suggests that factors contributing to missed primary care visits include patients forgetting, miscommunication about appointment logistics, competing life demands (eg, work), and unmet social needs (eg, transportation and insurance).^{10,12,15–18} There is limited research on patient perspectives of barriers to completing post-discharge primary care follow-up visits specifically.¹⁴ A better understanding of the patient perspective on missed appointments can inform patient-centered processes to improve access and quality of care during the critical transition period from hospital to home. As part of a health system quality improvement (QI) initiative to improve post-discharge primary care follow-up visit completion rates, the objectives of this QI project were to reschedule missed post-discharge primary care follow-up visits and identify patient-reported barriers contributing to missed visits.

Methods

This was a QI project, and the University of California, Los Angeles Institutional Review Board determined this project was not human subjects research. The practice setting was a large, urban academic health system with 2 hospitals totaling more than 700 total beds and more than 50 adult primary care clinics with over 5000 post-discharge primary care follow-up visits per year. Adult patients (age ≥21 years) with a primary care physician (PCP) in the academic health system who were discharged home from hospital medicine or emergency department services in the health system or external hospitals (ie, hospitals outside the health system) and who had a missed appointment for a post-discharge primary care follow-up visit type were included. Approximately 10% of scheduled post-discharge primary care follow-up visits in this health system were missed without cancellation. Practices for rescheduling missed appointments varied in modality and intensity of contact across clinics and by patients’ clinical risk factors.

For this QI initiative, on each weekday over a 6-week period (June–July 2024 as a time-limited pilot based on anticipated post-discharge visit volume and operational resources), a QI team member familiar with post-discharge visit scheduling and operations generated an electronic health record (EHR) report to identify missed post-discharge primary care follow-up visits without cancellation. Patients who were actively rescheduled by the patient or clinic, already completed a visit with a PCP, were readmitted, on hospice, or deceased were excluded. Care coordinators (N = 11) called patients to attempt to reschedule the primary care follow-up visit and assess and address patient-reported barriers that contributed to the missed appointment. Care coordinators documented patient-reported barriers in predefined categories (ie, patient forgot, did not know visit was scheduled, time did not work, did not feel the need to see PCP, transportation, financial or insurance, or other) informed by prior literature^4,10,12,15 and QI team and care coordinator discussions, call length, and brief qualitative comments when applicable. Patients were considered lost to follow-up if they were unable to be reached after 3 call attempts, including a voicemail with a callback number.

Using chart review from the date of discharge up to 30 days after discharge, a QI team member validated the proportion of patients reached by care coordinators and who completed the rescheduled visit among patients reached, and collected data on patient characteristics, including age, gender, ethnicity, preferred language, primary insurance, patient EHR portal activation status, CDC Social Vulnerability Index, and whether the missed appointment was confirmed with the patient when scheduled. Patient-reported barriers contributing to the missed appointment were discussed in meetings with QI and care coordinator team members and reported as counts. This QI project was reported according to SQUIRE 2.0 reporting guidelines.

Results

Among 36 eligible patients identified with a missed appointment without cancellation (Table 1), patients were mostly male, not Hispanic or Latino, had English as their preferred language, and had Medicare insurance. Of 22 (62%) patients reached by care coordinators, 18 patients (82%) were rescheduled for a primary care follow-up visit, and 11 patients (50%) completed the rescheduled primary care follow-up visit (Figure 1). Care coordinator call length was a median of 11 minutes (range 7–35 minutes).

Table 1.

Characteristics of Patients with a Missed Appointment Without Cancellation.

Characteristics	Overall	Reached by care coordinators	Unable to be reached by care coordinators
n (%)	N = 36	n = 22	n = 14
Age, years
21–40	8 (22)	4 (18)	4 (29)
41–64	12 (33)	7 (32)	5 (36)
65+	16 (44)	11 (50)	5 (36)
Male	22 (61)	12 (55)	10 (71)
Ethnicity
Hispanic or Latino	6 (17)	2 (9)	4 (29)
Not Hispanic or Latino	28 (78)	18 (82)	10 (71)
Choose not to answer	2 (6)	2 (9)	0 (0)
English preferred language	32 (89)	21 (95)	11 (79)
Primary insurance
Commercial	9 (25)	6 (27)	3 (21)
Medicaid	8 (22)	4 (18)	4 (29)
Medicare	19 (53)	12 (55)	7 (50)
Active patient EHR portal	31 (86)	17 (77)	14 (100)
SVI, median (range)	55 (3–98)	47 (3–98)	59 (9–87)
Initial missed appointment was confirmed with the patient when scheduled	11 (31)	9 (41)	2 (14)

Abbreviations: EHR, electronic health record; SVI, Social Vulnerability Index.

Figure 1.

Flow Diagram From Missed Appointment Without Cancellation to Rescheduled Visit Status.

Patient-reported barriers that contributed to the missed appointment included (1) missed communication opportunities (n = 15) (eg, did not know visit was scheduled [n = 6], did not feel the need to see PCP [n = 5], forgot [n = 4]); (2) access difficulties (n = 7) (eg, not feeling well [n = 2], each n = 1: wheelchair broke, unable to make it to visit, did not know how to do video visit, time did not work, financial or insurance issue); and (3) family or work-related issues (n = 2). Reasons patients did not feel the need to see their PCP or did not reschedule included that they were seeing specialists, had “a lot” of appointments scheduled, or overall felt well.

Discussion

Patient-reported barriers contributing to missed post-discharge primary care follow-up visits include missed communication opportunities and access difficulties. As part of a QI initiative, care coordinators used existing EHR report tools to identify eligible patients, reached most eligible patients, and incorporated patient perspectives in rescheduling missed visits. Since this pilot, the care coordination team has implemented standardized workflows for identifying patients with missed post-discharge primary care follow-up appointments. These findings highlight the importance of better understanding the patient perspective to inform targets for iterative QI in post-discharge primary care follow-up, including scheduling practices, discharge planning, and team-based outreach.

Even in this small exploratory QI project, there was variation in patient-reported barriers contributing to missed post-discharge primary care follow-up visits. Consistent with prior studies on missed primary care visits, the most common barriers included that patients did not know it was scheduled or forgot.^{10,12,14–16,18} In this health system, schedulers attempted to schedule visits for within 1 week of discharge and notify patients of appointment information by phone or mail; however, most missed appointments were unable to be confirmed with patients at the time of scheduling. To improve communication, health systems have aimed to confirm scheduling before discharge and implement visit reminders by text, call, or patient navigator outreach.^19–21 Recognizing that some patients may not feel the need to see a PCP, care may be co-managed with specialists, and timely access to primary care can be limited, health systems may consider which patients would benefit most from timely primary care follow-up and conduct team-based outreach using data on health care utilization (eg, emergency department visits, readmissions) and relevant health outcomes.^5,22–24 Inpatient teams may consider how to better communicate the value of primary care follow-up, recognizing potential stress and trauma of hospitalization,²⁵ and discuss patients’ concerns or questions before discharge to co-create a shared plan. Additionally, similar to prior studies on post-discharge PCP follow-up, several patients had access difficulties.^4,14 For these patients, health systems may consider tailored strategies to improve access, such as appointment accommodations for rescheduling, conversion from in-person to telehealth visits, and patient-facing telehealth technology support.

Although the QI project was not designed to detect differences in patient characteristics between those who were reached and unable to be reached, the approximately 40% of patients who were unable to be reached may be more likely to be younger, male, Hispanic or Latino, prefer a language other than English, have Medicaid insurance, live in an area with a higher Social Vulnerability Index, and less likely to have confirmed the initial visit when scheduled (Table 1). Prior studies have suggested that Black, Hispanic, and Medicare-Medicaid dual-eligible patients may be less likely to receive timely post-discharge primary care follow-up.²⁶ Telehealth may be associated with lower rates of missed appointments without cancellation and reduce disparities in access to care.^17,27 Future research may examine potential differences between patients who may be reached by care coordinators and those who are not,¹⁰ and seek perspectives of patients who may be less likely to be reached. These insights could inform interventions to improve care transitions for patients who may be most vulnerable.

Limitations of this work inform future QI efforts: (1) Given variation in clinic protocol for documenting missed appointments without cancellation in the EHR, there was variation in the timing of care coordinator outreach. (2) There were multiple care coordination programs that were ongoing at the time of this work. (3) This was a small sample specific to this health system context, and formal hypothesis testing for the effect of care coordinator outreach on visit completion was not conducted for this QI project. (4) Care coordinators were unable to reach about 40% of eligible patients, and results may not reflect the perspectives of patients who were unable to be reached.

These findings suggest that patient-reported barriers for missed post-discharge primary care follow-up visits reflect health system-level issues that may be addressed through interdisciplinary teams and processes that span care settings. Future work may consider which patients benefit most from timely primary care follow-up and how to determine when in-person or telehealth visits are appropriate for post-discharge primary care. Reframing “no-show” visits from a patient shortcoming to missed appointments without cancellation as a health system challenge may be more effective for identifying patients most likely to benefit and targeting interventions to improve care during a critical transition period.

Acknowledgments

The authors thank Elizabeth Jaureguy, RN, MSN, FNP, the UCLA Health Ambulatory Care Management team, and the UCLA Health Department of Medicine Quality Program. The authors thank Dr. Joann Elmore, MD, MPH for her helpful feedback on this work.

Conflicts of Interest

The authors have no conflicts of interest to disclose.

Funding

Dr. Zhang was supported by the US National Institutes of Health/National Center for Advancing Translational Science (UCLA CTSI Grant Number TL1TR001883), UCLA Department of Medicine, UCLA National Clinician Scholars Program, and UCLA Specialty Training and Advanced Research Program.

Author Contributions

All authors: Concept and design, acquisition, analysis, or interpretation of data, critical review of the manuscript for important intellectual content, and final approval of the manuscript. Drs. Simon and Dowling: Supervision. Dr. Zhang: Drafting of the manuscript.

Role of the Funder/Sponsor

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.