Best Practices: Best Practice for Managing Noncompliance With Psychiatric Appointments in Community-Based Care

Cope Behavioral Services, Inc., is a not-for-profit managed behavioral health care corporation located in Tucson, Arizona. Cope and the department of psychiatry at the University of Arizona College of Medicine forged a relationship from October 1995 to April 2001 to create an integrated service delivery system for approximately 1,500 adults with serious and persistent mental illness in Tucson's public mental health system. This program provided intensive case management services, inpatient psychiatric services, outpatient substance abuse treatment, crisis and emergency services, medication management, long- and short-term housing, individual and group psychotherapy, and social and recreational programming. All services were delivered at no charge to the client, and program costs were contained by a case rate funded by Medicaid and the state. The regional behavioral health authority that distributes all program funding in southern Arizona determined the case rate.

This integrated, flexible program assigned consumers to teams on the basis of risk factors—for example, morbidity, compliance, and the need for housing—and used consumer strengths to guide team decisions. Along with the consumer, the team included a case manager, a psychiatrist, a nurse, and other support staff. Case managers and case aides provided outreach services such as home visits, shopping assistance, and transportation to consumers as necessary. Case managers would see consumers a minimum of once a month, either in the community or in a clinical setting. As consumers required fewer interventions to achieve better functioning, the team adjusted the nature and frequency of contacts. The primary psychiatric diagnoses of the consumers in the program were mood disorders, including major depression, bipolar I disorder, and bipolar II disorder (37 percent); psychotic disorders, including schizophrenia and schizoaffective or schizophreniform disorders (37 percent); personality disorders, including types A, B, and C disorders (13 percent); and other axis I disorders (14 percent).

Four psychiatrists and one nurse practitioner provided psychiatric services. Policy dictated that clients who did not receive residential services had to go to one of three service sites to see a psychiatrist. Although psychiatrists offered a range of services, all clients who were taking medications were required to see a psychiatrist at least once every three months. Reminders in the form of visits or telephone calls from case managers were occasionally used to encourage clients to keep their psychiatric appointments.

Data were collected between January 1 and December 31, 1999, for clients who failed to keep their psychiatric appointments at the three service sites. Table 1 shows the annual rates of missed appointments by service site and individual practitioner. Rates were calculated for each psychiatrist, for each site, and for the system as a whole. Data for the nurse practitioner were incomplete and are not included. One psychiatrist—physician C—worked only until October, when another psychiatrist—physician D—assumed the position.

Large individual differences in rates of missed appointments by practitioner and site are evident. The rate of noncompliance for the system as a whole was 9.2 percent. On starting his new position, physician D noticed what he interpreted to be a high rate of missed appointments and began collecting and analyzing data on clients who failed to appear for their appointments over a period of 30 days (November 7 to December 7, 1999). Of the 152 scheduled appointments during that period, 33 (22 percent) were missed. Chart reviews and follow-up reports from the case managers of these 33 clients showed that 22 (67 percent) usually kept their psychiatric appointments and had frequent contact with their case managers.

Reasons for the failure of this normally compliant group to keep their appointments ranged from transportation and scheduling problems to the fact that they did not receive a reminder telephone call. Two clients (6 percent) did not keep their appointments because they were undergoing system transfers; one client was in the process of disenrolling from the system and was no longer taking medications, and the other had requested another physician. Nine (27 percent) of the clients who did not keep their appointments had a history of missed appointments and had generally not seen a psychiatrist for more than six months. These individuals had had their medication prescriptions refilled by telephoning their case managers. For half of these clients, substance abuse problems had been documented. They were at particular risk of receiving poor-quality care and presented an unacceptable liability risk. Hence this group was targeted for an intervention.

As a result of his analysis, physician D developed and implemented the following protocol at his site. Each time a client failed to appear for a scheduled appointment, physician D reviewed the client's chart to document the date of the client's last appointment, any pattern of missed or canceled appointments, and whether medications were being provided on an ongoing basis. Each client assessment was given to the site manager for the team to review and decide whether the client was an appropriate candidate for disenrollment, a reminder from the case manager, or some other action. This case-by-case approach clarified important client issues that could be addressed at the site-management level, such as the need to telephone clients before their appointments. Clients who had not visited a psychiatrist in six months and who had received a medication refill by telephoning their case managers were targeted for treatment compliance training.