Interventions for a Common Problem

Colleen Boehme

Current Philosophical Approach Behavioral Engagement Strategies

Contingency Management

Motivational Interviewing

Contingency Management

19 cocaine-dependent patients divided into a CM and control group.

Biweekly drug testing.

CM group: 2.9 weeks of continuous abstinence vs 0.6 weeks in control

Motivational Interviewing

104 patients w/ hazardous drinking habits, drug use within last thirty days and scored 15+ on Beck Depression scale

Randomized to receive three sessions of MI or printed literature about alcohol and drug use risks.

Telephone follow-up at 3 and 6 months

MI patients were less likely to report hazardous drinking (60.0 vs 81.8%).

Sticks work too 198 patients (42% psychotic, 31% MDD, 16% BP, 11% other).

Interviewed using various self-assessment scales As a direct result of services I received, I deal more effectively with daily problems.

Assessed four types of leverage Representative Payee

Condition for Housing

Condition of Probation

Involuntary Outpatient Commitment

Text Messaging 2008 (648) =no reminder

2009 (1081)=7 and 5 days

2010 (1088) =7 and 3 days

Percentage of Appointments Missed

2008=36%

2009=26%

2010=27%

Relative Risk Reduction

2008 and 2009 =28%

2008 and 2010=25%

Overbooking Increases Provider Productivity

Valuing the Variables Extra patient=1

Increased Wait=-.5

Overtime Costs=-1.2

Strengthening Treatment Access and Retention-State Initiative (STAR-SI)

2007, 10 states, 67 substance use disorder clinics

7 possible interventions

No Show Rate: Missed Appts/Expected Appts

Pre-average: 37.4% ; Post-average: 19.72%

Four Most Effective Welcoming Environment

Reduce Wait Times

Add Capacity

Behavioral Engagement Strategies

Reminder Calls was most popular intervention---19% decline in no-show rate

Review of 13 Controlled Studies Patient Misses Appointment

Send letter asking patient to reschedule

Send letter but automatically reschedule the appointment

No contact

5 weeks later

39% of those who were automatically rescheduled

17% of those asked to reschedule

9% of control group

A high no-show rate for the automatically rescheduled patients: 61%

Another Study New Patients Referred to Clinic

Letter with pre-assigned appt time

Letter instructing them to call and make appt

72% of the pre-assigned patients attended their appt

29% never replied, 8% replied but declined and 63% scheduled an appointment

The attendance rate in the self-scheduling group was 97%, which was higher than the pre-assigned group

And another

Patients randomly assigned to 4 possible interventions Orientation script read to pt when clinic called to schedule appt

Orientation script plus telephone reminder and clinic directions

Only the telephone reminder

Control: only appt time when initial visit was scheduled

Results: 28%

20% (69%)

32% (76%)

56%

Smart Strategies Schedule appointment for as soon as possible (within a week ideally)

Phone calls (& letters) are cheap and effective, especially when done within 48 hours of the appointment Make it personal and worthwhile, address obstacles

Try to get a verbal commitment to attend from the patient

Reminders work best when the patient feels like youre calling because you care about their well-being, and sincere attempts are made to overcome obstacles

Rewards Parking passes, food coupons, bowling passes, $3.00/session, milk coupons

for babies have all proved motivating to patients

Offering coffee, soda, candy, doughnuts etc to patients who attend sessions appears to be motivating and reflects caring

Also give praise and appreciation for showing up

Laganga, L., & Lawrence, S. (n.d.). Clinic Overbooking to Improve Patient Access and Increase Provider Productivity. Decision Sciences, 251-276.

Lefforge, N., Donohue, B., & Strada, M. (2007). Improving Session Attendance in Mental Health and Substance Abuse Settings: A Review of Controlled Studies. Behavior Therapy,1-22.

Mcniel, D., Gormley, B., & Binder, R. (2013). Leverage, the Treatment Relationship, and Treatment Participation. Psychiatric Services, 431-431.

Molfenter, T. (n.d.). Reducing Appointment No-Shows: Going from Theory to Practice.Substance Use & Misuse, 743-749.

Petry, N., Alessi, S., & Rash, C. (n.d.). A randomized study of contingency management in cocaine-dependent patients with severe and persistent mental health disorders. Drug and Alcohol Dependence, 234-237.

Satre, D., Delucchi, K., Lichtmacher, J., Sterling, S., & Weisner, C. (n.d.). Motivational interviewing to reduce hazardous drinking and drug use among depression patients.Journal of Substance Abuse Treatment, 323-329.

Sims, H. (2012). Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatric Services, 161-161.