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					                           Improving Noncompliance at UBHC

Introduction and brief history

University Behavioral HealthCare’s mission and values statements focus on providing
―accessible, efficient, effective and compassionate care‖. Clinicians at UBHC have been aware
for several years that certain problems detract from the efficiency and effectiveness of our
services. These problems involve clients who do not show for initial or follow-up appointments
or who are otherwise non-compliant with their treatment team’s recommendations. Staff were
struggling with questions such as: How can no-shows be prevented or reduced? When is it our
ethical and clinical obligation to terminate services for a client due to his/her propensity not to
show or be otherwise non-compliant with treatment? Are we being compassionate when we allow
such a client to stay in service or are we simply enabling him/her—possibly jeopardizing his/her
potential recovery while at the same time accepting significant levels of organizational risk?

There were several attempts to address different aspects of these noncompliance issues. Notably,
in 1999 a performance improvement team was chartered to look at no-show rates for initial
appointments (see full report Appendix A). Part of that study included a comprehensive literature
search to benchmark UBHC no-show rates, and to learn from published intervention attempts (see
Appendix B). In 2000, a small task force headed by a clinician supervisor attempted to specify
policies and procedures to address various noncompliance issues. The task force produced a draft
policy (Appendix C), but due to shifting responsibilities and other organizational changes, the
policy was never reviewed nor approved by executive committee and was not distributed to staff.

The current performance improvement team, the activities of which are documented below, was
chartered in September of 2001. The team used the general QI model approved by executive
committee in 1999 to guide their efforts (Appendix D). The following description will be
organized according to the four steps of the model: Plan/Design; Measure; Assess, and Improve.


Defining the problem

Effective, efficient, compassionate, and accessible care is undermined and adversely affected by
clients’ noncompliance with the treatment process. Noncompliance with psychiatric treatment is
associated with increased clinical, social, and economic costs and is closely linked to relapse, re-
hospitalization, and poor treatment outcome. Noncompliance can be expressed in different ways.
Primary among them is neglecting to show for scheduled appointments. Other expressions of
noncompliance involve refusing medication or not taking it consistently as prescribed and/or
choosing to accept one, but not other, essential elements of the treatment plan (i.e., accepting the
psychiatrist, but not the therapist and vice verse). Noncompliance is thought to be related to two
primary factors. The first involves factors external to the client, so-called ―systems issues‖ that
facilitate (or impede) compliance with attending scheduled appointments. The second involves
client factors (such as personality characteristics) that may lead to noncompliance with

individualized treatment plans. The team felt compelled to focus on system issues first. A
different approach was discussed, and was actually taken up by a separate PI team, working with
Extended Care clients (a mostly long-term schizophrenic population). That team decided to focus
on the client characteristics that impede memory for and follow-through with scheduled
appointments and established a weekly regular no-show clinic for clients who consistently were
not showing up for their scheduled appointments.

The noncompliance PI team described here made a decision to focus on improving the scheduling
system issues that affect the rate of no-shows in UBHC’s outpatient settings.

Specifying the participants

Several different functions and departments of University Behavioral HealthCare are involved in
the scheduling process.
 The Access Center (AC), which is the point of entry to the system for most new clients.
 The Transfer Center (TC), which serves as the entry point to outpatient services from other
    levels of care within the UBHC system and from without UBHC.
 Support staff at the outpatient treatment site, including registration (fiscal) personnel, the
    receptionist, and scheduling staff.
 The clinical service providers, including clinicians, advance practice nurses (APN) and
 Information Systems (IS). The computerized scheduling and medical record system is a key
    element that links all the different protagonists in this process.
 Administration.

In order to address all aspects of the scheduling process, the improvement team consisted of
representatives from each department and function listed above.

Members included:
Karen Marcus, Director of the Access Center;
Linda Shaw, Director of the Transfer Center and of Utilization management
Cynthia Tucker, Principal Management Assistant, and Shirley Lee administrative coordinator II,
representing support staff.
Gary Rosenberg, MD (team leader) and Kathy Finnerty, Clinician Supervisor, Somerset Brief
Treatment, representing clinical staff.
Bruce Blakeslee, Director, Information Services, and Shirley Chiou Project Leader, Information
Kathleen Quigley, Vice President for Brief Treatment.

Intervention Plans

The team reviewed the current appointment scheduling process at the Access Center and at the
outpatient unit level. (Appendix E). Analysis of the Access Center process revealed an need for a
small intervention to re-word the introductory letter sent to clients after they have made their first
appointment by phone. The re-wording was to emphasize the client’s need to assume

responsibility for his/her attending sessions regularly and to introduce the concept of a telephone
confirmation 48 hours before his/her scheduled appointment (Appendix F).

Review of the process at the unit level revealed that while the Access Center routinely confirmed
initial appointments by phone, confirmation calls for follow-up appointments were not part of the
existing process at the outpatient offices. The team targeted this function as a key element missing
from the scheduling process. Another missing element involved the capacity to closely monitor
and track clients’ adherence to the treatment schedule. There was no formal mechanism to notify
clients if they had missed a scheduled appointment; there was no mechanism to prompt clients to
re-schedule an appointment in order to maintain the continuity of their treatment, and there was no
mechanism to fill in gaps in the clinicians’ schedules left by no-shows and late cancellations.
The team felt that these issues should be addressed to improve the noncompliance rate.

The team envisioned a system whereby a no-show would prompt support staff to send a
notification letter, informing the client that he/she had missed an appointment. Clients would be
given a period of two weeks within which they were instructed to reschedule a substitute
appointment. If the client did not reschedule within two weeks, a second letter would be sent
informing the client that her/his treatment will be terminated (Appendix F). Two weeks after this
termination letter was sent, the clinician, physician, or advanced practice nurse would be advised
to close the client’s case.

The team wanted to computerize the new elements of the process so that the notification and
termination letters could be generated automatically based on specified criteria. This automation
was to prevent or lessen the burden this additional task would have placed on the support staff. A
computerized system would also keep track of total appointments, number and type of
confirmation calls, missed appointments, letter dates, and other tracking data. Such a system
would enable the close tracking and monitoring of the process and allow for mid-course
correction, should some elements prove to be less effective than expected.

The team felt that this process addressed clients who were consistently non-compliant in attending
their appointments. Addressing the consistently non-compliant client in this fashion could result
in a reduction in the clinicians’ caseload by eliminating from it this subset of clients. Such a
reduction might help increase productivity and efficiency, and ultimately improve the quality of
care of clients who do persist, cooperate and comply with their treatment plan.

Planning for data collection (database design)

A special database was designed for use by support staff and pilot tested. The database was
linked to the UBHC administrative database where all sessions are recorded (for fiscal reasons).
This feature is important because it means that if the pilot test were successful, additional UBHC
units could be phased in quite easily, with minimal changes in programming. The database
captured all appointments made for the participating clinicians, and queries were built in to select
clients who did not show within a specified period and generate a first notification letter for them.
Other queries checked for substitute appointments and time limits, and generated the termination

letter as needed. The database also records the type (whether personal contact was made or a
voice mail left), date of confirmation calls and the date letters were sent. Specification of the new
system’s functionality as well as the support staff functions related to it are attached (see
Appendix E).

The pilot

Edison Brief Treatment outpatient site was chosen to pilot test the new process. Six physicians
and one advanced practice nurse were the first set of treatment providers to participate in this
process. A collaborative team of the Edison support, registration and Information Services staff
was established to develop a protocol and work flow and specify the telephone confirmation of
appointments, the process of tracking missed appointment and the process of sending and
recording the notification and termination letters (see Appendix E). The physicians and advanced
practice nurses were encouraged to develop a ―hot list‖ of clients who could benefit from an
appointment sooner than their next scheduled one. These clients would be called if a confirmation
call discovered that a client was not planning to keep a scheduled appointment. The informed
consent for treatment was modified to include the fact that telephone confirmation calls would be
made and monitored. The database was programmed to display the roster of clients and their
appointments for the participating staff. During the pilot phase of the project, support staff,
information services staff and the treatment providers were scheduled to meet on a regular basis in
order to analyze and review the process.

Additional data would also be gathered during the pilot to track the process of confirmation calls
and case closures. These data included the number of phone calls required to contact a specific
client; how the message was delivered--direct contact with the client or the spouse, or voicemail;
the show rate of clients who were contacted, by the type of the contact, and the success rate in
scheduling another client into a freed up appointment slot. In addition, a time-effort study was
planned to determine the value of adding the confirmation function to the tasks of the support
staff. The pilot was to run (and did run) for three months, from April 2002 to June 2002.

Preliminary data shows that up to July 8th, 1,815 appointments were scheduled for the
participating providers. For those, 1,369 calls were made. Six hundred and sixty-eight clients
responded positively to the confirmation call and only 59 cancelled or wanted to re-schedule.
Four hundred and forty six calls were unsuccessful in reaching a client directly and getting a
response. Of the 1,369 calls made, 446 reached the client him/herself, 124 reached a spouse, 144
reached a parent and 100 another relative. 556 messages were left on voice mail.

Success indicators

The team firmly believed that this improvement plan would increase client compliance with
treatment, decrease ―no show‖ rates, increase success in filling cancelled appointments and thus
staff productivity, decrease caseloads for the treatment providers, and ultimately enhance client
treatment outcomes.

Plan for documentation and communication with management and staff

All PI team meetings were documented by minutes that specified tasks, roles, and time lines,
where appropriate (see sample minutes, Appendix G). Minutes were distributed to the Chief
Finance Officer, the Director of Quality Improvement and other managers as appropriate. In
addition, the improvement plan and issues involved in the pilot implementation were discussed
several times at the operations committee, which is comprised of UBHC leaders and managers,
and which is chaired by the President and CEO of UBHC (see excerpts, Appendix H). The PI
team efforts were also summarized and displayed as a poster presentation at the recent PI Fair,
conducted at UBHC in May, 2002. More than 200 staff visited the Fair, and the noncompliance
project received a fair amount of interest.


Baseline and Pilot Data

Baseline no-show and cancellation rates, productivity data, and caseload-size were reviewed for
the organization as a whole, for the Brief Treatment site in Edison, and specifically for the six
psychiatrists and the advanced practice nurse at the Edison site who participated in the pilot. In
addition to system data, some client characteristics including age, gender, and diagnosis, when
available, were also reviewed.

Quality Improvement has been monitoring quarterly data on no-shows for initial appointments as
well as no-shows and cancellations for follow-up appointments in the two major sites of UBHC,
Piscataway and Newark (see Appendix I). The Newark site has always evidenced higher no-
show/cancellation rates. Rates hovered around 25-30% for Piscataway sites and around 30-35%
for Newark sites.

No-show and cancellation rates for the Edison site showed that the combined rate of no-shows
and cancellations was reduced from 36.7% during the three months prior to the pilot (January-
March, 2002) to 32.6% during the three months of the pilot (April-June, 2002). These rates,
however, are for the entire unit staff, not just the seven providers included in the pilot. Individual
practitioner data were also reviewed (see Appendix J). The team is planning as the next
implementation step to include all staff at Edison Brief in the new process.

Review of the participating providers’ caseload and productivity figures for the three months prior
to and three months of the pilot have not yet shown a strong effect of the project. However, the PI
team members believe that the period of the pilot was too short to evidence major changes and
that the scope of the pilot was too limited (to only seven practitioners).

                                      ASSESS & IMPROVE

Team members felt that the pilot data were encouraging in that they demonstrated that the new
scheduling process was feasible. The data seemed reliable and have sufficient face validity for a
full-scale evaluation of process outcomes. Preliminary data revealed that the new process was
working well, missed appointments were tracked, letters were being sent, and gaps in clinicians’
schedules were being filled whenever possible. Some problems were revealed, involving the
interaction of support staff with the database and these are being addressed at the time of this

The team felt that while limiting the scope of the pilot to seven providers was good for testing the
reliability of the data and the new scheduling process, the scope was not sufficient to substantially
improve the no-show rate, nor to have the expected measurable effect on productivity and
caseload size. As a first step in further implementation the team is planning to continue the pilot
at the Edison site, increasing participation to all clinicians at this site. The next step would be to
implement the process at a different Brief Treatment site. Discussions are already under way with
managers at one possible site and there appears to be considerable enthusiasm on the part of these
managers to be included in the next phase.


The work of this noncompliance PI team was noteworthy in that it has demonstrated that focused
process improvement by all stakeholders (from multiple units and functions) involved in that
process can lead to a meaningful and fruitful collaboration.

The support and encouragement provided to this team (and other process improvement efforts) by
UBHC leadership is also noteworthy, and no doubt contributes to the preliminary success of this
PI effort. Clearly, UBHC leadership perceives the process under study to be important, with
marked potential to enhance the mission and values of the organization.

The work of this PI team constitutes an ongoing project, one which has not yet been completed
but which has already demonstrated the utility of the guidelines provided by the UBHC Quality
Improvement model.

This project will continue and expand, and its utility and effectiveness will continue to be
monitored and evaluated by UBHC leadership and staff. Ultimately, UBHC staff and leadership
are certain that rates of patient noncompliance with treatment can and will be reduced and that
such a reduction will enhance the quality of care for all UBHC clients.

   Appendix A
The 2000 no-show report


                                        Prepared by:
                                 Shula Minsky, Ed.D, Director
                                    Quality Improvement
                                      February 14, 2000


During 1999, data on no-shows for initial appointments were aggregated, analyzed, and presented
to the Executive Committee of UBHC. The analysis was based on data extracted from the Access
Center database, and attempted to explain (predict) no-shows using different demographic and
clinical variables such as gender, insurance, wait for appointment, and specific presenting
problems (e.g., Depression, Family issues, Substance abuse, Delusions etc.).

The conclusion of this analysis was that none of these variables allowed a prediction of the no-
show phenomena. We did find that there were substantial differences between units, with initial
no-show rates varying from 25% to 62% (See Figure 1). The overall UBHC rate was 39.8%.

A high no-show rate poses two major issues for UBHC: 1. We are here to provide services to
those who call us for help. A high no-show rate may point to some problem with access to our
services. 2. Clinicians have to free a relatively large percent of their time for the initial
appointments. A high no-show rate compromises service efficiency and adversely impacts
clinicians' productivity levels.

A Performance Improvement team (PIT) was convened in April 1999 to assess the situation and
devise strategies to address the no-show rate in a more proactive way.

PI team Members were:
Ed. Barrett, (Brief, Edison); Susan Brown (Access Center); Andy Coyne (Brief, Edison) Michael
Davie (Marketing); Lisa Debilio (Quality Improvement); Michael Gara (Quality Improvement);
Jerry Leventhal (QI, Newark); Karen Marcus (Access Center); Shula Minsky (Quality
Improvement); Nancy Randolph (Nursing Administration); and Rosemarie Rosati (Extended

The following report summarizes the methodology and results of two studies initiated and
completed by this team.

                                             STUDY I

To test the effectiveness of two different telephone interventions on reducing outpatient no-show
rates at units with no-show rates above the UBHC mean.
Clients calling the Access Center for outpatient appointments were randomly assigned to one of
three groups. In the first group, clients were contacted and reminded of their appointment by the
clinician, using a specially designed script. In the second group Access Center staff made
reminder telephone calls in the evening. The third group served as a control group in which usual
Access Center procedures were followed.

Three units participated in the study: 611 (Brief, Newark), 206 (Extended, Newark) and 160
(Extended, Piscataway). All calls for new admissions for an outpatient appointment in these units
were eligible for the study. However, some adjustments were made based on the amount of calls
for specific units (included only every third call for 611, because the volume of calls was much
higher then the other two).
Patients were excluded from the study who 1. requested that they not be called at all; 2. said they
did not have access to a phone; 3. requested that they not be called in the evening, and 4. were
below 18 years of age.

Access Center staff selected from the general log new appointments for the three units and entered
them on a data sheet (see attached). The sheet randomized callers into one of the three study
groups. Access Center staff also completed the identifying information on a clinician call log, and
sent/faxed the logs to the three units within a day.

The clinicians assigned to make the reminder calls, logged the number and status of contact
attempts on the clinician phone log. Clinician calls were limited to three attempts. Once the
clinician log was completed, it was sent/faxed to Quality Improvement for data entry and analysis.

Table 1 presents the total number of calls selected into the three groups of the study and the
numbers of clinician logs actually completed for group b (clinician calls).

                            TABLE 1: NO-SHOW STUDY
                                        SAMPLE SIZE
                               160:EC PISC   206: EC NWK       611: BT NWK      GRP TOTAL
Group a: AC evening call             34              31              34             99
Group b: Clinician call              48              44              44            136
        Logs received                21              29              32             82
Group c: AC routine reminder         28              39              27             94
Unit total:                         110             114             105            329

Data on the no-show status for all three groups was taken from the Access Center database. The
results are presented in Table 2.

                                   TABLE 2: NO-SHOW RATES
 Unit        Group                            Nodata     Registered     No-shows % no-show     p levels
 160: Extended Care Piscataway
             Group a: AC evening call             7            15           15         50.0
             Group b: Clinician call              2            12            7         36.8
             Group c: AC routine reminder         2            15           12         44.4
 206: Extended Care Newark
             Group a: AC evening call             7            13           10         43.5
             Group b: Clinician call              6            13           10         43.5
             Group c: AC routine reminder         9            23            8         25.8
 611: Brief Treatment Newark
               Group a: AC evening call           2            18           14         43.8
               Group b: Clinician call            0            20           12         37.5
               Group c: AC routine reminder       2            16            9         36.0
               Group a: AC evening call          16            46           39         45.9
               Group b: Clinician call           8             45           29         39.2
               Group c: AC routine reminder      13            54           29         34.9
               Overall:                          39            154          97         38.6
               Total N with results:            290

The p levels suggest that the three interventions were equally effective in reducing the rate of no-
shows for initial appointment. In an effort to see whether the amount of actual contact between
the clinician and the client made a difference, we classified the clinician logs into several
categories: successful contact at first call, contact at a later call, voice message or message with
another person, and no contact. The results, presented in Table 3, confirm our initial conclusion:
contact with the clinician did not affect the rate of no-shows.

           Table 3. No-Show Rates by Clinician Contact Type
                                         N      No-shows              %
           Contact at first call        29               9           31.0
           Contact at later call         8               3           37.5
           Message left                 14               6           42.9
           No contact                   25              12           48.0
           The rates were not significantly different. P=.66


We started the study with an intuitive belief that there is a difference between reminders that come
from clerical staff and those that come from clinicians. The results did not confirm our hypothesis.
No significant differences in the no-show rate were found among the three groups. The routine
reminder procedures of the Access Center were just as effective as other types of reminder calls.
It is interesting, though, to note that the overall no-show rate for the entire sample, irrespective of
group, was 38.6%, which is much lower than the rates seen for these three units last year (44.4%
50.5% and 57.1% for 611, 206 and 160 respectively).

                                             STUDY II


To learn directly from clients what reasons they had for not showing for a scheduled initial


The PI team developed a questionnaire (attached) that listed 9 possible reasons for not coming to a
scheduled appointment. An ongoing list of recent callers who did not show for their appointments
was compiled from the Access Center database. Included were only those clients who gave
explicit permission to be contacted by phone.


About 500 clients were on the list, and most of them were called at least once. By the end of
several months we had responses from 73 clients, a response rate of about 15%. Reasons for the
low response rate varied from disconnected phones, wrong phone numbers, moving away, to
failure to get the person at home. The results for the 73 who did respond are presented in Figure

In addition to the nine reason-statements, the questionnaire included an "other" option, to allow
respondents to give their own reasons, if they felt they were different from the given nine. Where
possible, we classified those "other" reasons into the same nine categories. Additional reasons
included various issues such as health problems, babysitting and forgetfulness, and are reported in
Figure 1 as "other".

Roughly equal proportions of the respondents said that the reason for their no-show was either
transportation (did not have a ride, have no car) or schedule changes that made the appointment
no longer convenient. About a third of the responses fell into the "other" category. The rest of the
responses had lower frequencies with 19 percent saying that they decided to go elsewhere for
treatment, 16 percent that they felt uncomfortable about seeing a therapist, and 12.3% that they

felt better, so there was no longer a reason to come. Only 2.7 percent mentioned the cost of
services as a reason for no-show.
                                                      Figure 1:
                                     Reasons for No-Show for Initial Appointment

                                40   4 2 .5
                                              4 1 .1

                                                       3 5 .6

                   Pe rce n t


                                                                1 9 .2
                                15                                          1 6 .4

                                10                                                      1 2 .3    11
                                                                                                                  4 .1
                                                                                                       8 .2
                                                                                                                         2 .7

                                      2         7      11         9          4           3        1    8      6          5
                                                                         R e as o n N u m b e r

                 2. I didn’t have a ride                             3. I felt better…
                 7. My schedule changed…                             1. I did not know how to get to the office
                 11. Other reasons (wait, health, babysitting,forgot)8. I decided therapy wouldn’t help
                 9. I decided to go elsewhere…                       6. I didn’t…talk to the therapist...
                 4. I was uncomfortable about seeing a therapist 5. ..It would cost more than I thought

 Phonesurvey.ppt QI, 2/14/2000


While the explicit reasons people gave for not coming to a scheduled appointment were varied,
most of them seem to suggest that the real reason behind the no-show phenomenon is either a
transportation problem, or a more subtle stigma issue and anxiety about getting into services. If
this is so, the appropriate course of action might be to try and address these hidden issues by
sending to callers information especially drafted to help people overcome their reluctance to
become involved in behavioral health services.

Final word:

The effort exerted by the Access Center staff and by the clinicians in the three units who
participated in Study I was greatly appreciated. The two studies clarified some of the issues
around the initial no-show rate at UBHC, and left some additional questions unanswered. We
have learned that reminder calls now being made are about as effective as they can be. We also
have some understanding of the reasons people admit to for their no-show behavior. It is possible,
and certainly supported by our literature search, that a certain proportion of no-show is
unavoidable in this field. However, we still may want to address the no-show rate with
administrative solutions such as mass evaluation that would allow double booking of clients, and
will conserve clinician time and effort. The other course of action would be to disseminate

appropriate educational materials to callers, in an attempt to help them overcome their anxiety and
fear of the stigma still attached to behavioral health services.

Appendix B
Literature Review

                                    No-Show Rates: Literature Search Results

Study Author &           N                      % No Show                   Conditions                     % No
Year                                              Prior to                                                 Show
                                                Intervention                                                after
Hochstadt & Trybula      N=88                  33%             1.   Received letter 3 days prior to       1.   32%
(1980)                   Adult, children and                        Appointment (n=22).
                         adolescent clients.                   2.   Received call 3 days before           2.   32%
                                                                    Appointment (n=22).
                                                               3.   Received call one day before          3.   9%
                                                                    Appointment (n=22).
                                                               4.   Received no intervention (n=22).      4.   55%

Kluger & Karras (1983)   N=141                                 1.   Orientation statement only (n=25).    1.   28%
                         Adult clients.                        2.   Orientation statement plus phone      2.   39%
                                                                    Prompt (n=41).
                                                               3.   Phone prompt only (n=25).             3.   32%
                                                               4.   Control (n=50).                       4.   66%

Palmer & Hampton         N=192                 38%             Participants called clinic for an intake        19%
(1987)                   Adult clients.                        appointment. Receptionist informed
                                                               the caller that the referral information
                                                               would be reviewed by the director of
                                                               the adult outpatient program who would
                                                               select the therapist best qualified to
                                                               evaluate/treat the presenting problem.
                                                               The caller was asked to re –contact the
                                                               clinic by phone on the following
                                                               workday to schedule a time for the
                                                               initial interview.
Swenson & Pekarik        N=150                                 Five conditions:
(1988)                   Adult clients.                        1. Letter prompt three days before         1. 37%
                                                                    appointment reminding client of
                                                                    date, time and agency name
                                                               2. Letter prompt one day before            2. 33%
                                                                    Appointment (n=30).
                                                               3. Letter orientation statement three      3. 27%
                                                                    days before appointment
                                                                    describing what a client should
                                                                    expect to happen during first
                                                                    appointment (n=30).
                                                               4. Letter orientation statement one        4. 17%
                                                                    day before appointment (n=30)
                                                               5. Control condition (n=30)                5. 43%

MacLean, Greenough,     N=327                    21.2%   The following four groups received one
Jorgenson & Couldwell   Infancy to 12 years of           of the following types of letters:
(1989)                  age and family’s.                1. (n =11) Change-slip reminder              1.   9.0%
                                                         requesting notification if time is to be
                                                         changed via a returnable slip portion of
                                                         the letter.
                                                         2. (n=26) Warning reminder                   2.   3.8%
                                                         indicating the possibility of losing place
                                                         in the waiting list should two
                                                         appointments be missed.
                                                         3. (n=18) Change-slip warning                3.   16.7%
                                                         combining both items 1 and 2
                                                         4. (n=20) Usual reminder requesting          4.   0.0%
                                                         confirmation of appointment time.
                                                         5. (n=252) Control group                     5.   20.6%

Webster (1992)          N= 74                            1.   Clients mailed an information sheet     1.   18%
                        Adults                                (n=39)
                                                         2.   Clients not receiving an                2.   43%
                                                              information sheet (n=35)

McKay, McCadam &        N=54                             1. Intervention included a 30 minute         1. 22.2%
Gonzales (1996)         Children and family.             telephone engagement intervention.
                        Study #2                         Intervention included helping the
                                                         caretaker invest in the help seeking
                                                         process by clearly identifying their
                                                         child’s presenting difficulties. By
                                                         framing caretakers actions as having the
                                                         potential to impact the current situation,
                                                         and having the caretaker take some
                                                         concrete steps to address the situation
                                                         prior to initial appointment. In
                                                         addition, phone intervention was an
                                                         opportunity to explore barriers to help
                                                         seeking within family and environment.

                                                         2. Control group (n=27)                      2. 51.9%

McKay, McCadam &        N=108                            1.   Focused telephone intervention, 30      1. 27%
Gonzales (1996)         Adults                                minutes (n=55)
                        Study #3                         2.   Business as usual telephone             3.   55%
                                                              intervention, relating to problems
                                                              of child and appropriate fit for
                                                              agency, 30 minute (n=53)

Henry, Ball & Williams   N=317                                        1.   Filled Pre-appointment            1.   7.76
(1998)                   Adults                                            Questionnaires (n=219).
                                                                      2.   Did not fill Pre-appointment      2.   41%
                                                                           Questionnaires (n=98).

               Additional Citations Reporting Missed Initial Appointment
          Year Study Author & Year                         Reported % Missed Initial Appointment
          Gallagher & Kanter (1961)                        23%
          Overall & Aronson (1963)                         57%
          Krause (1966)                                    44%
          Gould, Paulsen & Daniels (1970)                  20 – 30%
          Raynes & Warren (1971a)                          42.4%
          Gottesfeld & Martinez (1972)                     30 – 40%
          Rosenberg & Raynes (1973)                        30 – 40%
          Turner & Vernon (1976)                           30 – 40%
          Tantam & Klerman (1979)                          32%
          Larsen, Nguyen, Green & Attkisson (1983)         21%
          Palmer & Hampton (1987)                          38%
          Hochstadt & Trybula (1980)                       33%
          McLean et al (1989)                              21.2%
          Henry et al (1998)                               12.5%

          Methods of Increasing Patient Attendance
          1.      Information sheets explaining what would happen prior, during assessment and how decisions
                  about intervention would be made.
          2.      Telephone or mail reminder of the appointment.
          3.      Promoting positive physician-patient relationships.
          4.      Developing an intake screening system for identifying patients at high risk for non –compliance.
                  Predictive overbooking of appointments.
          5.      Assisting with transportation problems.
          6.      Providing behavioral reinforcement and incentives for keeping appointments.
          7.      Follow up failed appointments by telephone and letters.
          8.      Sending pre appointment packet of forms (ie; patient information and demographics, symptom
                  checklist, depression inventory and anxiety inventory).
          9.      Clinician contact with client prior to appointment.

      Appendix C
The draft Noncompliance policy

                                       NONCOMPLIANCE POLICY (Draft)


To establish guidelines and procedures for the termination of treatment of clients/patients for noncompliance with
treatment recommendations, or for non-participation in treatment. These guidelines are not meant to replace clinical
judgment, nor a patient's individualized treatment plan.


The Clinician Supervisor, under the supervision of the Clinician Administrator, is to ensure compliance with this


After two instances in which a client fails to show for a scheduled appointment, or cancels with less than 24 hours
notice, the case may be terminated by taking one of the following actions.

1.   If no risk factors are present, letters will be sent to the client/patient in the following
     a) After a missed appointment, a letter will be sent reiterating the need for regular attendance in treatment in
          order to ensure a successful outcome.
     b) A termination letter will be sent if the patient does not reschedule an appointment in 2 weeks after the initial
          missed appointment or doesn't show for a rescheduled appointment.
     c) If no appointment is scheduled within 2 weeks of the termination letter, or the patient doesn't show for a
          rescheduled appointment, the
          clinician/psychiatrist/APN will be advised to close the patient's case.

1.   If risk factors* are present:
     a) The clinician/psychiatrist/APN should make and document in a progress note at least 2 attempts to reach the
           client/patient by phone, coincident with the sending of the missed appointment and the termination letters.
     b) If the above efforts fail, the clinician/psychiatrist/APN can attempt to contact by phone or letter any
           authorized contact (e.g. family member, DYFS worker, primary care physician) that may be of assistance in
           returning the client to treatment.

          * Risk factors are defined as hospital discharge in past year; suicidal or homicidal ideation in past year;
          active thought disorder; GAF below 50; or other serious and dangerous behaviors that place the patient at
          risk for death and/or bodily injury to self or others.

1.   In the following circumstances, the clinician and psychiatrist/APN will discuss the noncompliance in the
     treatment team meeting:

a)   When the client/patient complies with pharmacotherapy, but resists recommended psychotherapy, the treating
     physician will:

     1) Address with the client/patient the fact that treatment if unlikely to be successful in these circumstances.
     2) Consider the option of a change in clinician if this will enhance the treatment if approved by the original
     3) Suggest that the client's pharmacotherapy be monitored by their Primary Care          Physician.

          4) If a non-compliant patient is at high risk or if the pharmacotherapy is too complicated for the PCP to
             monitor, the psychiatrist will provide for all of the client's/patient's needs with periodic reevaluation to
             determine if any of the above outlined actions become clinically appropriate.

     a)   When the client/patient complies with psychotherapy, but refuses or is non-compliant with pharmacotherapy, the
          treating clinician should:

     1)       Address with the client/patient the fact that treatment is unlikely to be successful in these circumstances.
     2)       Consider the option of a change in psychiatrist/APN if this will enhance the pharmacotherapy if approved by
              the original psychiatrist/APN.
     3)       Consider option of termination of therapy if clinically indicated.

         When a high risk patient is refusing a recommendation for transfer to an appropriate higher level of care, the case
should be reviewed in the treatment team meeting with the clinician administrator of the unit. If still unresolved, the case
                                may be referred to the Clinical Case Review Committee.

 Appendix D
The General QI Model


                                                              Why do this? What are the objectives? Does it fit
                                                     PLAN     overall mission, values, plans? What are the
                                                              expected results? Who must be involved? What
                                                              exactly will we do? for how long will we engage in
                                                              this activity? How will we measure baseline
  If it works, implement,
                                                              performance? How will we measure outcome?
  disseminate, publicize, do
  training and in-service, and
  maintain gains.

                 IMPROVE                                            MEASURE

                                                                                 Collect relevant baseline and outcome
                                                    ASSESS                       data, analyze, compare with past
                                                                                 performance and with external
 Evaluate the results, interpret, discuss, is the
 new process/ strategy/improvement useful?
 Practical? Cost-effective?

           Appendix E
The workflow and database specifications

  Workflow for the New
                                                  Pt calls
  Appointment Scheduling
                                                AC gathers
                                                clinical and
                                                fiscal info

                                                    AC                                              Yes
                   Welcome letter               schedules 1st                        Permission
                                                    appt                              to call?

                                               AC notifies
                                              unit (IC form)                    AC make

             Record as
                                           No        Pt shows for
           missing appt in                            1st appt?
           letter (send                           Unit sched FU
           and record)                                 appt

                                                48 hr prior to appt:                      Cancel?         Yes
                                                confirmation call
      No       Pt. re-       Yes
               sched.?                                                                    No               Schedule
                                                                                                          client from
                                                                                                            hot list
                                                     Pt. show for
                                                      FU appt?
Termination                                              No
letter (send
and record)

                                        Record as
           2 wks                      missing appt in

  Close case
                                      letter (send and

                                                                      Termination       2 wks       Close case
                                    Yes    Pt. re-       No                                                                  End
                                                                      letter (send
                                                                      and record)

Show/No-show Performance System Functions

This pilot study includes only the MDs and APNs in Edison
Brief office

    A. Increase the productivity of MDs and APNs

The criteria to send a notification letter:

Select only those clients that they had missed the appointment(s) (―NoShow‖ only, and only apply
to face-to-face contact) which were scheduled in the time frame specified by the user. However, if
a client came in for another service either in the same unit or in different unit, this client will not
be selected.

Only 1 notification letter will be sent even if a client had missed more than one appointment.

The criteria to send a termination letter:

Select only those clients which the Notification Letter has been sent 2 weeks ago. The system will
check the entire database to see if they have made a new appointment since that date, or if they
had kept this new appointment since that day. If the answers are all negative, then a termination
letter will be sent.

The criteria to select a client to be terminated

The purpose of this function is to list the clients who have not attempted to make a new
appointment after the no-show or have not kept an appointment in the last 4 weeks. It has the
same criteria as above (―termination letter‖). Only this time we select the clients based on the
―termination letter‖ flag. A report will be printed and it will be distributed to the MDs or APNs
for further review.

    B. Monitor the future appointments

The future appointments can be displayed and users can make reminder calls to the clients about
their appointments. If a client intends to cancel the appointment, the vacant slot can be filled
immediately from the ―hot list‖ which contains a list of client’s phone number and desired dates
in case of a cancellation. This ―hot list‖ is maintained by the staff in each office.

                               Appointment Monitor database

                        User Procedure (revised as of July 2, 2002)

Please follow the procedure every Wednesday. Since we started on April 10th, I will use this
date as the starting point.

Week 1 : On April 10th, a Notification letter should be sent to those clients who missed the
appointments from 4/1/02 to 4/5/02. After the letters have been printed, the ―Notif. Letter sent out
date‖ in the database will be marked as ―4/10/02‖.

Week 2: On the following Wednesday, 4/17/02, another Notification letter should be sent to those
clients who missed the appointments from 4/8 to 4/12. After the letter have been printed, the
―Notif. letter sent out date‖ will be marked as ―4/17/02’.

Week 3: Now, on the third Wednesday, 4/24/02, 2 letters should be sent out:
        First: Notification letter for 4/15 to 4/19. The ―Notification Sent date‖ will be 4/24/02.
        Second: Termination letter. When you open the second red box on the form from the
database, you will have to select a DATE from a drop-down list; there should be three dates
displayed: 4/10/02, 4/17/02, and 4/24/02 (assuming you just sent the notification letter out). On
the drop-down, select the first date, which is 4/10/02. Because 4/24/02 is 2 weeks after 4/10/02,
the date that the first batch of letter went out. After the letter have been printed, the ―Term. letter
sent out date‖ will be marked as ―4/24/02’.

Week 4: On the fourth Wednesday, 5/1/02, 2 letters should be sent, like previous Wed.:
       First: Notification letter for 4/22/02 to 4/26/02. The ―Notification Send date‖ will be 5/1.
       Second: Termination letter. You will select ―4/17/02‖ from the drop down list (there will
be 4 dates for 4 weeks) and select a desired program. Since 5/1/02 is 2 weeks after 4/17/02. The
―Termination letter sent out date‖ will be marked as ―5/1/02’.

Week 5: On the fifth Wednesday, 5/8/02, 2 letters should be sent , plus a Termination List will be
        First: Notification letter for 4/29/02 to 5/3/02
        Second: Termination letter. This time, you will have to select ―4/24/02‖ from the drop
down list. Since 5/8/02 is 2 weeks after 4/24/02.
        Termination List: Open the third red box on the main form (No show performance
Screen), select a date from the drop-down list, then select a desired program. Now there should be
2 dates displayed: 4/24/02 and 5/1/02.. Select 4/2402 as your target date because 4/24/02 is the
date you sent the FIRST batch of termination letters out.

From this point on, every Wednesday you will have to send 2 letters out, and print a termination
list for APNs and MDs.

See following for a graphic description of the procedure

Date and       4/10         4/17         4/24         5/1         5/8         5/15
Notification   yes          yes          yes          yes         yes         yes
Termination    no           no           yes          yes         yes         yes

Termination    no           no           no           no          yes         yes

Note: When sending Termination letter, always select an appropriate ―Notif. Letter sent date‖
from the drop-down list. Don’t worry about what date range from the previous week. Remember:
always select the date which is 2 weeks before today.

When generating Termination List, always select an appropriate ―Term. Letter sent date‖ from the
drop-down list. Don’t worry about what date range from the previous week. Remember: always
select the date which is 2 weeks before today.

           Appendix F
   The Access Center revised letter
The notification and termination letters

                        The Access Center revised welcome letter


Welcome to University Behavioral HealthCare. We are pleased that we have been chosen to
participate in your health care. Our exceptionally well-trained mental health staff will do all that is
necessary to make this experience as helpful as possible. Your experience with UBHC will
begin with a formal evaluation that will help define your problems and will result in a treatment
plan that will identify goals and objectives for your therapy. If therapy is recommended, regular
attendance in therapy sessions will enhance the positive solution of your problem. Therapy
appointments may be confirmed by telephone by UBHC two days in advance. If you cannot
keep a scheduled appointment, please contact your therapist with at least 24 hours notice so
that another appointment can be rescheduled and another patient can be scheduled in your

This letter confirms your appointment and explains our registration process. Your reserved
appointment is with:

                            on:                           at:

Please be on time for your initial appointment which will include registration with a financial
counselor. The entire registration process and the evaluation may last one and one-half to two
hours. The financial counselor will request the following items from you:

            Driver’s license
            Insurance information 1) ID card, and 2) SUBSCRIBER’S Social Security
            Payment for your co-payment and deductibles

The financial counselor will assist you in reviewing your insurance benefits. If you have no
insurance, you will be responsible for the fee. A reduced rate may be available if you qualify; it
is based on your and your family’s income.

If you must cancel or reschedule your initial appointment or have any other questions regarding
our services, please give at least 24 hours advance notice by calling 1-800-969-5300. We look
forward to meeting you. Directions to our office are enclosed.


Vice President, Level of Care


                            The Notification and Termination Letters
Notification Letter:

May 13, 2002

In order to monitor your medication, I must see you on a regular and frequent basis. According to our records, you
did not attend your last scheduled appointment. Therefore, I cannot effectively monitor your medication, nor can I
continue to prescribe medication for your effective treatment. If you already arranged a follow-up appointment or
contacted your clinician/psychiatrist/ advanced practice nurse regarding this absence, please disregard this notice.

If you would like to continue treatment with me, please call (732) 235-8400 within the next two weeks to reschedule
an appointment.

Thank you for your attention to this matter.


Termination Letter:

May 21, 2002

According to our records either you did not reschedule an appointment, or you rescheduled one and failed to keep it
after receiving the previously sent notification letter that you missed your last scheduled appointment. As a result, I
can no longer effectively provide treatment for you. As stated in the introductory letter, I cannot provide effective,
safe and quality treatment if you do not regularly attend scheduled appointments. If you have already arranged a
follow-up appointment or contacted your clinician/psychiatrist/advanced practice nurse regarding this absence, please
disregard this notice.

I suggest that you contact your primary care physician or your health insurance provider if you require further
treatment, as I can no longer be responsible for your care. If you require mental health services in the future, please
call our Access Center at 800-969-5300.

Thank you for your attention to this matter.


     Appendix G
Sample Team Meeting Minutes

                             UBHC-BRIEF TREATMENT SERVICES
                                   MINUTES OF August 14,2001. TIME: 1 1:00 a.m.

                             Next Meeting: September 6,2001.
                             Time:     10:30-11:3 0 a.m.
                             Place:  UBHC-BTS, NORTH BUILDING-Piscataway

1.   Confirmation of appointments by telephone.

     A).       Access Center confirms their appointments, two days prior.

              If patient does not show, this is recorded in CSM by the receiving unit
              There is no outreach to reschedule.

     B).       Edison Brief (1700 visits/mth)- 6 physicians, 2 support staff.

                Call 2 days prior to scheduled appointment with/or MD/APN
                It takes approximately two hours to complete the confirmation calls which are made
                   in the evening.
                       a. Contact made 75% of calls
                       b. Approximately 10% inform staff that they will not be attending their

                The face sheet is a tedious mechanism to use as the source of the patients' phone
                Presently not making a second call to fill a cancelled appointment.

         C).     Development of Pilot Projcct in Edison Brief.

                 •   Need Database of patients phone numbers that is user friendly.
                 •   Should include a field in CSM registration to indicate, whether or not patient
                     has provided consent to call. (In addition to the consent form. completed, during
                     the registration process).
                 •   Access Center screen includes some telephone information in the initial contact
                 •   Phone numbers should be printed on the daily schedule for each MD/APN. (The
                     absence of a phone number should indicate that the patient didn't give consent
                     to make confirmation call).
                 •   A waiting list will be developed by each M.D/APN so that a few patient can be
                     scheduled, if a patient cancels
                 •   The support staff' (Senior Receptionist/Patent Scheduler) will work with the
                     clinical supervisor to coordinate the confirmation process.

        D. Centralized versus local calling site.
                     The waiting list could be on a shared drive database.
                     Can schedule from centralized site.

        F_ Tracking data for a 2 month period.
                      1. # of calls made
                      2. %of calls that yield a cancellation,
                      3. # of calls made to reschedule another appointment from the waiting list.
                      4. Time involved to make the above calls.
                      5. No show/cancellation rate to compare to a 2-month equivalent period, prior to the
                           initiation of the pilot program.
                      (6 MD,'APN Productivity)
                      (7 No show /cancellation rate for clients who confirm their appointment

II.         Letters-Missed appointment/termination.

            A) Transfer Center has a process to manage the scheduling of their patients.
                    ·    They confirm all appointments.
                    ·    If client didn't keep scheduled appointment, a letter is sent
                         encouraging the patient to make an appointment. (With a copy of the letter sent to
                         clinical supervisor).

          B) Pilot Project in Edison Briet
        1. Clean up CSM so that the primary clinician is properly identified and caseloads are accurate.
        2. Missed appointment letter (attached) will be sent to all patients who miss an appointment.
                a) MD/APN/Clinician will be notified.
                b) Phone contact will be at discretion of the physician/APN and occur if clinically
                c) Staff person will record the date the letter is sent.
                     If patient has not made an appointment within 2 weeks of the date, the missed
                     appointment letter was sent, the termination letter will be sent.

       3.         a) MD/APN/Cllnician will be notified if termination letter (attached.) is sent

                  b) If no appointment is made within 2 weeks after the letter is sent the MD/APN and
                     clinician will be informed that the case should be closed.

       4.      The -MD/APN and clinician treatment team should be discussing the clinical implications of
             this process in the treatment team meeting since the process can bc a1tcred if clinically indicated.


             1. A representative of IS will be invited to become a member of the team in
                 order to assist in the development of mechanisms Within CSM –that will be applicable to the
             2. Include a member of BRTI to assist in the data collection and review process.

       3.    Establish a connection with the Ql committee.

Attendance: Dr. G. Rosenberg; K. Quigley; K. Marcus- C. Tucker: A.Weinkrantz;
            L. Shaw.

Cc:         W. Dineen; C. Trotman; M, Massa; Blakeslee, Bruce-, S. Minsky; D. Chin

                MINUTES OF September 10, 2001. Time: 1:00-2:00


I.     Confirmation calls:

        A. Phone number accessibility.
           1. IS can provide list of7patients with phone numbers who are scheduled to be seen
              in 2 days
           2. Shirley Chiou can develop the database.

        B. MD/APN develops hot list of patients to be called.

           1. Clinician supervisor may help coordinate the list.
        C. Evaluation appointments
            1. Access will not call to confirm, the unit will.
            2. If patient cancels, will use pending list/internal referral to reschedule another
            3. Will reschedule an appointment with a voice to voice contact, not by leaving a
                message or voicemail

II.    Time Effort Study:
      A. Kathleen Quigley and Cynthia Tucker will develop a project outline
      B. To determine if the revenue earned by increasing MD/APN productivity, will pay for the
          staff to run the program

III. Letters
A. IS. in an already existing format, can track the MA/T letters
B. IS can also possibly produce the letters at each she.
C. Which support staff person will perform this function
           1) Does not make sense to carve into someone’s workflow,
           2) Should be done by the designated staff performing the confirmation
             3) Explore option of hiring a temporary staff to initially manage the program

Attendance: Bruce Blakeslee; Karen Marcus; William Dineen; Linda Shaw;
Gary Rosenberg, MD; David Chin; Kathleen Quigley; Tucker, Cynthia.
        Cc: Cordell Trotman; Shula Minsky; Alan Weinkrairtz.

                        MINUTES: October 9th, 2001.


I      Confirmation calls:

A.        Shirley Chou will use CSM to develop database that will streamline
          1. Unit will type in name and telephone number of patient retrieved from Access
               Center-with AC as non-billable initial service code.
          2. An icon on desktop will allow staff to access the list of those patients who require
               confirmation of their appointments.
          3. Another icon will produce the data for the missed or termination letter process
               (See below).
          4. Need to develop the hot list procedure for MD/APN-will contact MD/APN's in
               Edison for their ideas.

II     Letters: Missed/Terminate.

          A. Will be able to print out the letter for each client who either missed an appointment
             or who are being terminated from treatment.
          B. Will also be able to print the list of patients who were sent a letter two weeks prior
             to the selected date.
          C. Will check if can produce the daily M/T/list with the information that indicates
             whether or not the patient has rescheduled an appointment.

III    Treatment noncompliance:

           1.   Kathleen Finnerty reviewed the draft of treatment noncompliance policy (see
           2.   Treatment plan should be developed by the second session so that it can be
                signed by the patient.

IV     Time effort study:

           1.   Need to gather more data in order to determine the fiscal benefits/risk of the
                pilot study.
           2.   Do we centralize or decentralize the tasks described above.

Attendance: Gary Rosenberg; Sharon Eaton; Shirley Chiou; Kathleen Finnerty; Bruce

Cc: Karen Marcus; William Dineen; Linda Shaw; David Chin; Kathleen Quigley; Cynthia
Tucker; Cordell Trotman; Alan Weinkrantz; Shula Minsky;
Calla Waldron

                          NONCOMPLIANCE PI TEAM, December 4, 2001


A.   M/T Letter Databases

     1. CSM has a 3-day delay in identifying patients who no showed for an appointment. This will
        generate the missed letter.
     2. CSM Termination Letter Database generated 2 weeks after missed appointment.
     3. CSM hot list can print on a daily basis (day range)
     4. "Not seen in 90 days"  letter needs to be developed
     5. Format letters to fit window envelope with block letterhead
     6. Will not develop letter for missed eval appts. Need to develop a missed appt. letter for
        clinician, and another for first appointment with a MD/APN and clinician for intra-unit

A.   Transfer Center - Should flag Transfer Center appointment in CSM since Transfer Center has its
     own confirmation/follow-up system.

     1.              Follow patients to ensure continuity of care - phone patient if no show for
             appointment with letter as follow-up after first contacting the unit to which they are

             a) Database of transferred patients already in the system
             b) Transfer Center support staff:                 one person - adult/IP/PHP
                                                               one person - adol IP/PHP
                                                               one person - all other transfers
             c) If patient no shows, will contact the clinician and send letter to the patient (see
             d) If patient is scheduled through Access Center, the Access Center also calls to confirm
                the appointment

A.   Confirmation Calls

     1. CSM will develop database - # calls that contacted the client, # calls that resulted in left
        message with other, # calls that resulted in left message on answering machine
     2. When client registers, should enter preferred number to call to confirm

             a) Will check with CSM to determine if this field can be added to the database.

A.   When expand to entire system

     1.               Can adopt databases to include all clinicians
     2.               Access Center will confirm all Access Center evaluation appointments.

A.   Pilot project will last for the 1st quarter in order to compare to quarterly data collection already in
     place re: no shows, cancellations.

             Committee will meet again one month into the pilot project to reassess.

                               NONCOMPLIANCE PI TEAM

ATTENDED:              Linda Shaw, Melody Massa, David Chin, Shirley Chiou, Gary

A:   Access Center Letter
             1.       Will query patient when they make contact with the Access Center
                      As to whether or not they will give permission to call to confirm
                      Their appointment and/or to send the welcome letter.
             2.       Will send the Edison Pilot Project letter to all Edison patients
             3.       Shirley Chiou will program access to the letter from the
                      Computer network.
             4.       The need for the Transfer Center missed appointment letter will
                      Ultimately be unnecessary once the pilot program expands to include all clinical staff.

B.   Data Collection
             1.      Shirley Chiou will collect the data for the months January
                     Through June 2002 comparing January through March to the
                     Pilot project April through June.

                       a.       No show rate
                       b.       Productivity
                       c.       Show rate based on type of contact (direct contact versus voice mail message)
                       d.       No show rate for those who confirmed their appointment
                       e.       Rate of scheduling new patient if original patient declined their appointment

C.   A policy needs to be developed for the Access Center to deal with the terminated
     patient who calls to schedule a new evaluation appointment

              1.       Will need to develop a mechanism to identify those patients whose treatment was
                       terminated for noncompliance
              2.       The clinician should be consulted prior to rescheduling another evaluation.

D.   Notification/Termination letters and the informed consent form will be reviewed
       by legal (David Chin will be responsible for this) and then reviewed by the   clinical documentation

                                             Appendix H
                        Excerpts from Operations Committee Minutes
                                   OPERATIONS COMMITTEE MEETING
                                           September 4, 2001

4. Gary Rosenberg, MD, medical director, Brief Treatment, led a discussion regarding the outreach
   effort process (the no-show policy). The goal is to develop a formal process that can be used across all
   clinical sites. Brief Treatment was selected as the pilot site. Dr. Rosenberg distributed draft copies of
   the performance improvement team’s no-show policy.

                                     OPERATIONS COMMITTEE MEETING
                                             January 24, 2002

12.    Gary Rosenberg, MD, medical director, Child and Adolescent Services, announced that the   pilot project to
       reduce the no-show rate was started in Edison.

                                   OPERATIONS COMMITTEE MEETING
                                            July 26, 2001

2. Gary Rosenberg, M.D., medical director, Brief Treatment, led a discussion regarding physician
   productivity and what must be done to allow physicians to consistently meet the minimum standard of
   23 direct service hours per week (i.e., no show factors, instituting a missed appointment fee, outreach
   efforts, creating a policy that restricts physicians from prescribing medication for patients who have
   not been seen within 90 days).

      At this time, Wordprocessing staff will not be able to assist with the outreach efforts as these staff
      members are working on transferring information from previously dictated initial evaluations to the
      core assessment.

      Karen Marcus, director of the Access Center, Kathleen Quigley, director of Brief Treatment, Linda
      Shaw, director of Utilization Management, David Chin, director of Clinical Records, Alan
      Weinkrantz, chief financial officer, Dr. Rosenberg and various support staff members will work on
      outreach efforts, tracking these efforts and instituting a missed appointment fee. At the next
      Operations Committee, Dr. Rosenberg will come back with a recommendation for an operationalized

                     Appendix I

Organization, Site and Pilot Data related to Noncompliance

                          Organization-wide data

                                     No Shows for Initial Appointments
                                                  2000-2002, by quarter











               Q 1-2000   Q 2-2000    Q 3-2000     Q 4-2000       Q 1-2001   Q 2-2001   Q 3-2001   Q 4-2001     Q 1-2002

                                       P is c ataway                                        Newark

               No Show and Late Cancellations of Follow-up appointments









               Q 1-2000   Q 2-2000    Q 3-2000         Q 4-2000   Q 1-2001   Q 2-2001   Q 3-2001     Q 4-2001    Q 1-2002

                                       P is c ataway                                         Newark

     Age and Gender for Edison Brief Clients

                       Jan-Mar, 2002            Apr-June, 2002

                        M              F          M              F

Sessions              41.20%          54.80%     43.30%      56.70%

No-shows              44.50%          55.50%     49.40%      50.60%

Other cancellations   37.10%          62.90%     37.60%      62.40%

Sessions                       39.5                       38.8

No-shows                       31.8                       32.1

Other cancellations            41.5                       40.7

                       No Shows and Cancellations at Edison Brief

                         Jan-Mar,               Apr-June,               Jan-
                       2002                     2002                    June,2002
                           N               %       N             %
Sessions                    4,408       63.3       4,868         66.4         9,276
No-shows                     962        13.8       1,040         14.2         2,002
Other cancellations         1,594       22.9       1,424         19.4         3,018
Total services              6,964                  7,332                    14,296

Note: During the pilot, combined percentage of missed appointments was reduced from
      36.7% to 32.6%.

   Diagnostic Distributions for Clients
With and Without No-Shows and Cancellation

Diagnostic Category                 Sessions   No-shows   cancellations
Adjustment disorder                   12.9        15.7       13.7
ADHD                                   4.5         5.3         4.2
Anxiety Disorders                      7.5         9.1         7.3
Major Depression                      21.8        25.5       23.8
Schizophrenia and other psychosis      0.8         0.3       0.96
Bipolar disorder                       1.4         1.8         1.8
Substance Abuse                       44.3        33.8       41.8
Other diagnoses                        6.8         8.6         6.5

Individual Data for Providers Participating in the Pilot

               January      February      March           April           May           June

Productivity        92.3          93.6            95.4            68.6          71.1
No Show             13.4          12.5            12.1              9.1         13.2       18.0
Cancellation        15.7          17.1            13.9            13.6          15.1       13.5
Case Load            158           175             179             153           156        155
Productivity        73.2          72.8            67.2       122.6              81.0
No Show             10.2          13.0            22.7        16.8              11.4       15.5
Cancellation         8.5          13.9             8.3        11.0              37.1       18.2
Case Load
Productivity        84.5          70.2            63.1            72.0          77.2
No Show             10.5          15.8            15.7            11.3           6.1       11.3
Cancellation        18.6          22.4            35.7            26.3          15.9       32.1
Case Load             81            81              73              67            88         79
Productivity        83.1          83.2            92.0            87.4          86.1
No Show             16.5          13.9            12.4            13.4            8.6      14.9
Cancellation        17.0          13.3            22.2            16.1          23.4       18.8
Case Load            141           149             147             149           152        158
Productivity       112.8          77.6            89.4       101.0          101.0
No Show              8.5          22.2            14.3        17.5           22.0          16.7
Cancellation        14.9          13.9             3.2        10.0            6.6          11.9
Case Load             40            43              52          72             80            82
Productivity        79.6          87.7            82.3       105.6              82.3
No Show             12.3          11.3              6.3         8.1             15.2       10.6
Cancellation        18.1            8.3           26.6        31.4                6.0      17.9
Case Load            131           147             141         131               147        138
Productivity        70.9          81.6            89.3            86.6      101.5
No Show               0.0           0.0             0.0             0.0        0.0           0.7
Cancellation        18.9          20.8            22.2            15.5       14.3          13.2
Case Load            129           128             140             135        116           139


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Description: Sample Psychotherapy Letter Patient Termination document sample