Absent Patient

A chronic problem with individuals who are homeless and have little structure in their lives is frequently missed appointments. Sadly, the people in the greatest need of help are often not about to keep appointments or readily trust those associated with health services. When they fail to attend their initial or follow-up sessions it is associated with increased risks of more serious oral deterioration and is a substantial waste of dental care resources, clinic efficiency and volunteer goodwill.  Not surprising dental appointment making (and keeping) among homeless patients is driven mostly by immediate symptoms and a desire for pain relief. Once these needs are met and they start to feel better they often see no reason to return for additional care.

Our clinic stats show that the non-attendance rates of patients with pre-booked appointments is approximately 37%.  This no-show rate is consistent with that reported in the literature for homeless patients (i.e. 35%-55%) and is about 4 times greater than in typical private practice dental settings (i.e. 5-10%). There was a moderate degree of monthly variation with best attendance in December (23% no-show rate) and worst attendance rate in July (45%). Not surprising, those with a history of functional impairment from substance abuse and psychiatric difficulties were the worst “offenders”.  Younger age and day of the week (i.e. Fridays) were also associated with greater risk of missing appointments.

We have been able to reduce the net negative impact of no-shows in our clinic to just 15%. This has been due to the positive counter-balancing effect of employing a partially open-access scheduling system to accommodate walk-in patients and emergency attendees as well as pro-active “corralling” of prospective clients right off the streets when no-shows occur.

Fortunately, much can be done to improve appointment attendance rates through various intervention measures. There is a reasonable evidence base in the “complex client” literature to support the following simple approaches that we all can take to improve commitment levels:

• Provide a welcoming, non-judgmental atmosphere,
• Give prompt, convenient appointments (i.e. reduce wait times),
• Determine if no-show cause is legitimate (i.e. illness, accident, administrative errors, fear/anxiety, transportation issues, perceived lack of respect, etc),
• Offer open-access (same day) scheduling (i.e. walk-ins),
• Overbook schedules based on individual patient no-show rates,
• Consider low cost incentives,
• Strengthen patient’s perception of clinician “helpfulness”,
• Provide reminders if possible,
• Put the client’s goals at the centre of planning,
• Enhance patient’s insight/information regarding treatment,
• Engage family/peer supports in treatment planning,
• Consider patient sanctions (i.e. withdraw of all but emergency services after 3 incidents) with reinstatement after 6 months,
• Request more information on intake form regarding client’s contacts, including family and case managers.