D.33 VISN NO SHOW POLICY.pdf

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

HEART OF TEXAS HEALTH CARE NETWORK

Network Policy Memorandum 10N17-11-19 December, 2015

Processing of No Show Clinic Appointments

I. PURPOSE: To establish a policy and procedure for assuring continuity of care, monitoring of patients who fail to report for scheduled visits and to reduce missed clinical opportunities for Primary Care, Mental Health, and Specialty and Acute Care. Patients who “no show” for their assigned clinic appointment are a major cause of missed opportunities. The “no show” patient fails to receive needed care and decreases timely access to care for other Veterans.

In order to become maximally efficient in providing access to patient care, this policy will specify our approach to managing patients who fail to show for scheduled appointments.

II. POLICY: Charts of all patients who fail to show will be reviewed at the end of each clinic session. Local policies will guide which team member reviews these records. Clerical support staff will document in the VISTA software package when the patient fails to show for the clinic appointment at the end of the clinic session and will provide a no show list to the clinical team, who will determine the appropriate plan of care. The follow-up plan will be documented in the patient’s electronic health record.

III. SCOPE: This policy is intended to document the expected care of patients who no-show for a clinic appointment. It has been designed to clarify issues regarding the missed appointment and scheduling of future appointments.

IV. RESPONSIBILITIES:

A. The Chief of Staff, Service Chiefs, Managers, Coordinators, and appropriate providers are responsible for ensuring the development and documentation of a patient plan of care for missed appointments and for future appointments in accordance with this policy.

B. The Service Chief, Managers and Coordinators are responsible for insuring that all clinic staff are aware of this policy and comply with its contents.

C. Each staff member of Primary Care, Mental Health, Specialty Care and Acute Care are responsible for knowing the contents of this policy and complying with the established procedures for no-show appointments.

D. The Chief Medical Officer and VISN Systems Redesign Coordinator are responsible for the update of this policy three years from the date of issue or sooner if deemed warranted.

D.33 RFP: 36C25722R0015

V. PROCEDURES:

A. If a patient fails to report for a scheduled Primary Care, Mental Health, Specialty Care or Acute Care appointment, the appropriate clerical support staff (clerk) or Patient Service Assistant (PSA/MAS) will record a “no-show” in VISTA through Appointment Management Menu options.

B. By the end of the clinic session, the clerk/PSA will provide a list of patients who no-showed for their scheduled appointments to the responsible provider, surrogate or designated team member, who will review each patient’s medical record, including any consult or procedure request received or associated with the appointment and then determine, document and initiate an appropriate plan of care. If directed to reschedule the patient, the clerk/PSA will follow procedures prescribed in their local scheduling policy.

1. Primary Care. The provider/designee will review the patient’s chart to determine the need for medication renewals and follow-up on laboratory and/or diagnostic tests and will document an appropriate plan, including follow-up appointment in a No Show Progress Note.

Patients who repeatedly no-show should be contacted by phone and/or letter to explain that failure to report for additional appointments will be considered a refusal to accept treatment with an explanation that they will be unassigned from the primary care panel if future no-shows occur.

Once unassigned, a patient’s medications will only be renewed for a limited time as deemed necessary by the provider.

2. Specialty Care. For a new patient, the Specialty Care provider will document on the consult that the patient failed to keep the appointment. The Specialty Care provider will review the medical record to determine whether the patient is low risk versus high risk. If the patient is low risk, a no-show letter will be sent requesting the patient call and reschedule. The consult will be discontinued if there is no response in 14 days, and the Primary Care Provider (PCP) will be invited to re-consult as needed. The PCP receives an automatic notification that the consult has been discontinued. For established patients who are low risk, the provider will identify the PCP as an additional signer of the “no-show” note. A no-show letter will be sent requesting the patient call and reschedule. Patient medications will only be renewed for a limited time at the discretion of the provider. If the patient is high risk, attempts will be made to contact the patient by telephone. A no show letter will be sent if unsuccessful after two attempts to contact the patient via telephone. The no show letter for the high risk patient will instruct the patient to contact the service in order to re-schedule the appointment. If the patient no shows twice, the service can discontinue the consult or follow-up plan and return the patient to the PCP.

Systems may have policy for consult discontinuation for patient driven missed opportunities to include both no shows and patient driven cancellation. A consult may be discontinued after one no show when combined with such events.

3. Mental Health.

New Patients: For new Mental Health (MH) patients referred by consult who no show for their initial consult appointment, the provider or other designated clinic staff with access to CPRS will make three attempts to contact the patient by telephone and enter a "No Show Note Mental Health" into CPRS documenting the outcome of the telephone call attempts. If the provider or other clinic staff member is able to reach the patient by telephone, the caller will document the reason for the no show and offer the patient an opportunity to reschedule. If the caller is unable to reach the patient by telephone, a no show letter will be mailed to the Veteran. In either case, the provider will discontinue the consult according to MH consult guidelines. If the Veteran cannot be reached by telephone or elects not to reschedule, the referring provider must resubmit a new consult if the patient still requires and is willing to accept MH services.

Established Patients: For established MH patients who no show, the provider or other MH staff member will make three attempts to contact the Veteran by telephone enter a "No Show Note Mental Health" into CPRS documenting the outcome of the telephone call attempts. If the caller is able to reach the Veteran by telephone, the caller will document the reason for no show and offer the patient an opportunity to reschedule. If the provider is unable to reach the patient by telephone, this shall be documented in the "No Show Note Mental Health" and a “No Show Letter” will be mailed to patient. If two consecutive no shows or three no shows within one calendar year and within the same MH clinic are recorded, the provider will note such in the “No Show Mental Health Note.” The provider will then review the Veteran’s CPRS record and contact the Veteran by telephone to discuss possible discharge and care planning as appropriate (this should be accomplished during the three telephone call attempts to follow-up on the patient’s no show). If the Veteran cannot be reached after three documented attempts, the provider may request that a discharge letter be sent to the Veteran. The provider will advise the Medical Support Assistant (MSA) or Patient Services Assistant (PSA) if the Veteran is to be discharged from the MH clinic and if a clinic discharge letter is to be sent to the Veteran. Of note, only licensed independent providers (LIPs) may determine clinical appropriateness for discharge and authorize such actions. Non-LIP staff must review such cases with their supervising LIP and document this review and concurrence in CPRS. Contraindications for discharge may include but are not limited to: a current PRF (Patient Record Flag) for high risk behavior, recent suicidal or parasuicidal behavior, and severe mental instability within the last 6- 12 months as indicated by recent psychiatric hospitalizations. Providers must document results of their chart review, patient discussion, and care planning in CPRS outlining the decision to discharge or retain a Veteran in MH services who has met the no show discharge criteria. At no time shall the PSA send a clinic discharge letter to a patient without approval from the provider or Service Chief to do so.

Attempted Contacts by Provider: For all no shows, at least THREE attempts to contact the Veteran must be made at varying times and each attempt must be documented in CPRS. Calls must include any mobile phone numbers and work phone numbers listed, taking care not to reveal to others that this involved a mental health appointment. Veterans with a High Risk for Suicide Patient Record Flag or otherwise deemed to be at imminent risk of harm to self/others must be called by an LIP, be reported to the facility Suicide Prevention Coordinator and consideration given to initiating a health and welfare check by local police if not reached/evaluated by telephone. Staff supervisors will audit compliance with all no show policies described above by performing periodic chart reviews.

C. Exceptions or special circumstances will require the approval of the provider or Service Chief.

VI. REFERENCES: VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures. Memorandum, Clarification of Veterans Health Administration (VHA) Outpatient Scheduling Policy and Procedures and Interim Guidance (#7588555).

VII. RESCISSION: Network Policy 10N17-11-19 dated March 2011.

VIII. REVIEW DATE: December, 2018

Joseph Dalpiaz Network Director