Conversion of No-Show Patients to Telehealth in a Primary Medicine Clinic

Abstract

No-shows in primary care clinics prevent patients from receiving essential care and decrease clinic productivity. The COVID-19 pandemic forced physicians to adjust to telemedicine as a necessary method to provide care. In this study no-show patients were converted to telehealth visits thereby allowing physicians to care for their patients and maintain hospital revenue. The most common reasons for “no-shows” were found to be forgetting appointments and transportation issues.

Introduction

Patients who do not show up to their scheduled appointment, known as “no-shows,” cause a disruption in clinic productivity and patient care.¹ The reasons for no-shows are variable, but common issues are forgetting appointments and miscommunication.² Despite how widespread this issue is, finding a solution to decrease no-show rates has been a struggle for physicians and administrators.³ The COVID-19 pandemic forced physicians to rapidly transition to telehealth to provide care.⁴ This transition enabled physicians to continue to provide medical care and maintain hospital revenue at a time when many institutions were financially burdened. Despite the difficulty in the transition, telehealth has certain advantages for patients such as decreasing the stress of travel or missing wages.⁴ It also enables patients to continue receiving regular preventative care. Patients who do not attend their appointments may have worse health outcomes. For example, patients with low attendance in diabetes clinics are associated with worse glycemic control.⁵ The purposes of this study are to determine if no-shows can be converted to successful telehealth visits and to determine the most common reasons for patient no-shows, thereby potentially increasing productivity and lessening the gaps in patient care.

Methods

Overview of Design

This study occurred from December 2020 to March 2021 using information collected by medical students and clinic staff.

Study population

Patients aged 18 years or older who were scheduled for a follow-up visit to the Truman Medical Center Gold 7 Primary Care Clinic and were not checked in within twenty minutes of their appointment were included in the study. Patients scheduled for a new patient visit to establish care or a Well Women’s visit were excluded from the study.

Methodology

Patients who were considered no-show, meaning they were not checked in within 20 minutes of their scheduled appointment time, were called using a secure hospital number by a medical student (Figure 1). If the patient did not answer, they were called again five minutes later. If the patient answered, they were asked the reasons for missing their appointment, and subsequently asked if they would like their missed appointment to be switched to a telemedicine visit. Patients who agreed to have their visit switched were immediately converted to a telemedicine appointment that was conducted by a medical student and the attending physician. Patients not interested in a telemedicine appointment were rescheduled for an in-person visit, as they normally would be by the clinic staff. For the purpose of this study, these patients were not followed up on as they were mostly scheduled for in-person visits. The patients’ responses as to why they missed their appointment and if they were willing to have a telemedicine visit were documented in a de-identified manner on a spreadsheet.

Figure 1.

Flow Chart

Statistical Analyses

Only de-identified data was used in conducting the analyses. Patients scheduled for clinic on the days of the study were counted, and the rate of conversion to telehealth encounters was calculated. Patient responses as to why they did not attend their appointment were assigned to categorizes such as “forgetting” and “transportation” (Table 2). Statistical analyses were conducted on data derived from these clinical encounters (Tables 1, 2).

Table 2.

Major Reasons for No-Show (from patients who answered the phone)

Forgot about appointment	17	50.00%
Transportation	6	17.65%
Would not be able to make appointment at scheduled time	4	11.76%
Other*	4	11.76%
Weather	3	8.82%
Total	34

^*Reasons such as illness, lack of childcare, or scheduling error

Table 1.

Total No-Shows and Conversions to Immediate Telehealth Visits

Total Scheduled Patients	215
Total No-shows	69
No-shows who did not answer their phone or were establish care visits	35
No-shows who answered phone	34
Total conversions to telehealth	27
Percent of total no-shows	32.09%
Percent of no-shows who answered the phone	49.28%
Percent of no-shows who answered the phone and agreed to immediate conversion to telehealth	79.41%
Percent of total no-shows converted to telehealth	39.13%

Results

Over the course of 20 clinic days and 215 total patients, 32% of the patients were no-shows and 79.41% of patients who answered the phone agreed to have their visit converted to telemedicine (Table 1). The most common reasons for no-shows were forgetting (50%), transportation difficulties (17.65%), timing (11.76%), and weather (8.82%) (Table 2).

Patients who were considered no-show, meaning they were not checked in within 20 minutes of their scheduled appointment time, were called using a secure hospital number by a medical student. If the patient did not answer, they were called again five minutes later. If the patient answered, they were asked the reasons for missing their appointment, and subsequently asked if they would like their missed appointment to be switched to a telemedicine visit.

Discussion

Ability to Convert to Telehealth

This study highlights the importance of telehealth in providing medical care, especially when patients face barriers to attending in-person appointments. During the COVID-19 pandemic many patients feared coming into the hospital, especially the elderly and immunocompromised.⁴ Telehealth platforms enabled physicians to continue providing medical care in a safe and socially distanced manner.⁶ While the COVID-19 pandemic forced the medical community to utilize telemedicine, it has shown to be useful in also reaching out to patients who no-show to their in-person visits.⁷ Overall, no-show rates declined at the Primary Care Clinics during the COVID-19 pandemic with the widespread use of telehealth. In December 2019 through February 2020 the average no-show rate at the Truman Medical Center Primary Care Clinics averaged at 30.22%, and from December 2020 through February 2021 the rate was 26.79% (Table 3). Although this study was conducted during the winter months, the no-show rate during these months was similar to the rate during other seasons. For example, the average no-show rate at the Primary Care Clinics from June 2020 to August 2020 was 27.56% compared to the no show rate from December 2020 through February 2021 which was 26.79% (Table 3). In this study, the no-show rate was 32.09% in the Gold 7 Primary Care Clinic and almost 80% of no-show patients who answered the phone agreed to have their visit converted to a telemedicine encounter decreasing the no-show rate by 6%. The most common reason for patients who answered the phone and refused telehealth was that they preferred to have an in-person visit, which was scheduled at a later time. In the Gold 7 Primary Care Clinics, clinics are run with medical students who make the initial phone calls for conversion. Additionally, the clinic staff was utilized to help with phone calls and scheduling. Once a patient agreed to a telehealth visit, the front desk staff was notified who immediately converted the appointment to a telehealth visit in the electronic medical record or rescheduled the patient for a later date. This did not create any major disruption in clinic flow as the general clinic policy of a 20-minute grace period for no-shows was followed.

Table 3.

Comparison of No-Show Rates before and during the COVID-19 Pandemic

Pre-Pandemic
Month	Year	All Clinics No Show %	Gold 7 Clinic No Show %
December	2019	31.45%	22.73%
January	2020	30.50%	30.05%
February	2020	28.70%	28.77%
Average		30.22%	27.18%
Pandemic
March	2020	31.86%	18.03%
April	2020	22.78%	20.50%
May	2020	34.22%	33.61%
June	2020	31.71%	No patients seen
July	2020	26.79%	29.48%
August	2020	24.17%	32.56%
September	2020	27.59%	25.54%
October	2020	25.95%	25.97%
November	2020	26.87%	19.35%
December	2020	27.34%	11.81%
January	2021	25.16%	19.89%
February	2021	27.88%	27.63%
March	2021	26.34%	16.28%
Average		27.59%	23.39%

Exploring Reasons for No-Show

In previous studies, the most common reasons for patients not attending their appointment were forgetting, feeling better and no longer seeing a need to attend appointments and transportation issues.⁸ In addition, extreme weather has been associated with failure to attend scheduled appointments.⁹ In this study the main barriers affecting adherence to in-person visits include forgetting appointments and lack of dependable transportation, which is similar to previous studies on no-shows in clinical practice. In the primary care clinics used in this study, patients are given a text message reminder one day prior to their appointment and a phone call a few days prior. Patients are also sent mail-in reminders if phones are not listed as the preferred method of communication. However, there are many patients who do not have cell phones or other reliable contact methods, including consistent mailing addresses, therefore excluding them from receiving these reminders. The use of data collection tools could be useful in tackling the issue of no-shows. By gathering information on reasons for frequent no-shows, solutions specifically tailored to those patients can be found.¹⁰ Various methods such as sending text messages, phone calls, mail-in reminders or messages through a patient portal could be implemented to see what works best in a particular clinic.¹⁰ These barriers, especially forgetting appointments, will be further investigated in future projects to determine how the clinic’s reminder system can be optimized.

Transportation was the second most common reason for patients in this study to not attend their scheduled appointment. Access and type of transportation has previously been considered a social determinant of health as patients cannot attend in-person appointments without proper transportation.⁹ In addition, travel distance is usually higher for lower income populations than higher income populations.⁹ By switching to telehealth visits, patients can receive care in the comfort of their homes without the additional stresses of arranging transportation to clinic. It is also important to note that this study began in the winter months, and periods of extreme weather, such as temperatures below 0°F and snowstorms, occurred during the study. Because weather was reported as a common cause for no-shows in this study, the results may have been different if conducted during another time of the year.

Effects on Patient Health

Patients who do not attend their appointments may have worse health outcomes.¹¹ For example, patients who frequently miss their appointments are less likely to be up to date on their health maintenance and more likely to have higher hemoglobin A1c values and poore blood pressure control.¹¹ As missing appointments can lead to long-term negative health effects and impede patients ability to receive preventative care, it is important to decrease the number of no-shows in primary care clinics.

During the COVID-19 pandemic, reaching out to patients through telehealth became even more imperative as some patients feared coming into the hospital. As a result, the rates of emergency department visits for stroke, STEMI, domestic violence, and psychiatric issues declined.¹² While a telehealth visit may not be able to completely help a patient during an urgent care visit, it can at least provide a mechanism for physicians to quickly direct patients towards seeking appropriate and sometimes lifesaving care. While the effectiveness of telehealth visits are still being studied, it can be assumed that patients who converted to telehealth visits were able to have better continuity of health care than if they were never called after they missed their appointment. In fact, a previous study found that out of 1,734 patients surveyed, 94–99% of patients were “very satisfied” with telehealth and one third preferred telehealth to an in-person visit.¹³

Telemedicine and Social Determinants of Health

The hospital at which this study was conducted, Truman Medical Center, is a safety-net hospital in urban Kansas City, and its continued use of telemedicine is greatly impacted by the population it serves. In other studies, the increase in telemedicine was shown to be higher in areas with low poverty levels and within metropolitan areas.⁷ This may be due to the fact that patients from lower socioeconomic backgrounds or rural areas may have difficulty accessing the stable internet connection and sophisticated technology needed for telemedicine.¹⁴ Interestingly, those without insurance are more likely to prefer telehealth to in-person visits.¹³ In addition, telemedicine also requires a degree of digital literacy which certain populations, such as the elderly, may struggle with. Consequently, telehealth has been demonstrated to be used less among older adults.¹⁵ In the patient population of this study, many patients did not have video visit capabilities or were elderly and did not have the digital literacy to operate a video visit. However, many of these patients were comfortable with simply speaking over the phone. While telemedicine has shown to be beneficial in improving patient outcomes, physicians should be aware that not every patient will have the capabilities for a telehealth visit.

Telemedicine and Insurance

It is important to note that before January 1, 2020, the use and payment of telehealth was inconsistent by state and insurance; thus, greatly limiting the use of telemedicine formats.⁴ In January of 2020, telehealth use was expanded as the 2018 Bipartisan Budget Act was enacted, which removed some requirements to help expand the use of telemedicine. One of the reasons for this expansion was because telemedicine was forecasted to save $557 million over the next 10 years for Medicare Advantage enrollees.⁴ Although there is an economic case to be made, the main reason for telemedicine expansion should be to close the gaps in healthcare delivery and improve public health. Gaps in healthcare delivery can be met by telehealth visits and decrease the burden on a suffering healthcare system. When the COVID-19 pandemic became apparent in the United States, the Centers for Medicare and Medicaid Services relaxed rules using a temporary waiver allowing Original Medicare enrollees the same telemedicine benefits that were given to Medicare Advantage enrollees and providing equivalent reimbursement for video telemedicine and traditional in-person visits.⁴ As these changes, among other provisions for telehealth, are using temporary waivers, the future of telehealth and reimbursement are unknown.⁴ While many studies have shown the benefit of telehealth,^6,13 it is unlikely that it will be used to the same capacity in the future if there is not equivalent reimbursement for physicians.⁴

Hospital Revenue

Additionally, the COVID-19 pandemic led many hospitals and practices to lose revenue. Many elective procedures that typically generate large amounts of hospital revenue were suspended in order to conserve personal protective equipment and reduce the spread of the virus.¹² By reaching out to patients via telehealth, physicians can continue to provide essential care without facing major financial losses.¹⁶ With telehealth, primary care physicians also have the ability to make referrals to specialists and order labs which results in helping maintain hospital revenue and quality patient care. The large patient no-show rate (32%) and the percentage of those who were converted to a telemedicine appointment (79.41%) demonstrate that telemedicine can be utilized to provide patient care and maintain clinic productivity (Table 1).

Conclusion

Telehealth allows patients to have a visit with their physician despite an ongoing global pandemic, forgetting appointments, and transportation issues. Virtual visits benefit healthcare professionals by increasing clinic efficiency, preserving hospital revenue and most importantly maintaining continuity of care for the patient. Despite limitations to this study such as the length of the study and a smaller sample size, the results highlight the value of telehealth to patient care. Telehealth may not work for all patient populations, so further studies need to be done to improve access to care for these patients. With the goal of increasing healthcare accessibility and eliminating barriers to care, Gold 7 clinics will incorporate this methodology into their daily clinics with hopes to expand to other Truman Medical Center clinics. Future studies will also examine patient satisfaction with telehealth visits and analyze the best scheduling methods to decrease no-show rates.