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[00:00:00] Hello everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you in part by TherapyNotes.

TherapyNotes is in my opinion, the best EHR for testing psychologists. If you’re on the hunt for an EHR and you want to give them a shot, you can get two free months by going to thetestingpsychologist.com/therapynotes.

This episode is brought to you by PAR.

The new PAR training platform is now available and is the new home for PARtalks Webinars, as well as on-demand learning and product training. Learn more at parinc.com\resources\par-training.

[00:01:00] Hey, welcome back y’all. Glad to be here with you for a business episode.

Today we’re talking about no-shows. No shows as we all know are a huge pain in the ass. Even though we are largely protected from testing appointments no-shows, intakes are another story, at least in our practice. We’ve implemented many strategies over the years to combat no-shows, but today I’m diving into the literature to see what the scholars have to say about reducing no-shows or “non-attendance” as some of the articles put it. So if you struggle with no-shows at all, this episode is for you. And really, who doesn’t? Who does not want to reduce their no-shows?

If you’re a practice owner and you’re looking for some group coaching or support, I believe at this point, our cohorts for January 2024 have closed, but there is always a chance that there’s a spot or two [00:02:00] left. You can check out more info and schedule a pre-group call at thetestingpsychologist.com/consulting. And if there are no spots in the group, there is always a chance that I have an individual spot available as well. So happy to talk with you and figure out which option might be best for consulting.

All right, let’s talk about no-shows and how to reduce them.

Okay, everyone, we are back. We’re talking about no-shows. So much to talk about when we are thinking about no shows. We all deal with no shows. Like I said, it’s less common in testing, but it certainly happens.

Our biggest problem with no-shows happens on the adult [00:03:00] side. We do well with pediatric appointments, parents show up, and they are ready to get their kids tested. They do not typically no-show those intakes, but on the adult side, we have a little bit of a problem. I would say that maybe 20% of our adult intakes no show.

People book the appointments several months out and then either forget or find services elsewhere, and that leads us to experience a good number of no-shows on the adult side. Little did I know that the time between booking and the actual appointment is a predictor of higher no-show rates, which we will talk about as we go along. 

If you’ve ever struggled on those shows, we’re going to dig into the reasons people no show, no show rates, and of course, strategies to reduce no shows. Rather than list all of the strategies that might work,[00:04:00] I’ll do that too, but I want to dig into the actual research on reducing no-shows.

Now, this may come as a surprise, maybe not, it wasn’t surprising to me that there’s not much out there, honestly, especially for reducing no-shows in mental health and especially not for reducing no-shows in private practice. Any studies that have focused on mental health tend to be outpatient clinics like community mental health or other more formal entities. So doing a little bit of conjecture here, but I think there is some good data to extrapolate from.

That said, no-shows are an age-old problem. The earliest published article that I could find was published in 1983, so 40 years ago. It’s not just the kids these days so to speak, although we will find out that age does play a role in the likelihood [00:05:00] of no-showing.

Let’s start with some reasons. Why do people no show?

If you are anything like me, you default to the assumption that people are no-showing purposefully. What we know, though, is that this is not the case. It is not typically a purposeful disregarding of the provider or of the appointment that leads people to no-show. Much more often it is being sick, logistical issues like lack of transportation, scheduling conflicts, or simply forgetting.

Forgetting about the appointment, I read in one research article, can account for something like 30% to 40% of no-shows as people just simply forgetting about the appointment. Again, it was hard for [00:06:00] me to wrap my mind around this because I just assume that if people are no showing, those folks are similar to myself and I tend to have pretty good executive functioning.

If I don’t show up to something, it’s usually because I chose not to in a deliberate or thoughtful way, although thoughtful is a little bit misleading because I’m not always thoughtful about how I don’t show up. But that is not the case. People do not typically purposefully disregard the appointment, acknowledge it, and then decide not to go and just not say anything. Much more often, like I said, it’s these external factors, logistical issues, or they’re just forgetting. But we do know that there are some demographic factors related to higher no-shows and some non-demographic factors. So, these are the top three. I’ll just give you the top three.

The number one predictor for whether someone [00:07:00] is going to no-show is whether they have previously no-showed an appointment. This is less relevant with testing because we don’t tend to get many repeat customers. It’s not like people come back for intakes every single week or something, but it can tell you if you are having trouble getting someone to come in for the intake, if they no show once, the likelihood is pretty high they’re going to no show the next one too. So keep that in mind. Previous no-shows are the biggest predictor of whether folks are going to no-show again.

Appointment lead time is a big factor in no-shows. This may not be surprising, but more lead time led to more no-shows. So the longer an appointment is scheduled from when the person books it, the higher the likelihood they’re going to no-show.

Now, the articles that I looked [00:08:00] at tended to use increments of either 15 or 30 days and they stopped at 60 days out. Many of us are booking much further than 60 days out, right? So again, we’re extrapolating a bit, but there was a direct linear relationship between the time from booking to the time of appointment and the likelihood of no show. So the longer the appointment was booked out, the more likely the person was to no show.

The third factor that is related to higher no-shows is age. Again, I don’t know if this is surprising or not, but the age group of 21 to 30 had the highest no-show rate, folks over 60 had the lowest no-show rate, and other age groups were between. [00:09:00] Essentially, 21 to 30, 31 to 40, and 41 to 50 had the highest no-show rates. Little kids and older adults tended to have the lower no-show rates. So a few things to consider.

There are certainly some articles you could dive into. I got in the weeds on this topic where folks are building out models for predicting no-shows based on a dizzying array of demographic factors. And there are some actually pretty impressive, comprehensive, and complicated models out there for predicting no shows. These are typically used in bigger hospital systems and outpatient clinics and so forth but that literature is out there if you want to check it out and it’s fascinating how they built these models.

Okay. We’ve got some reasons why [00:10:00] people no show and some factors that are related to higher no-shows. Let’s talk just briefly about no-show rates. This is going to vary greatly. That’s the overarching statement here. But what we know, medical practices tend to vary quite a bit. I have seen articles that say about 6% to 7%t of appointments will no show in a medical practice all the way up to an average of 20%. A lot of variability there.

Mental health private practices, this is anecdotal from being in a variety of Facebook groups and talking with other practice owners, mental health, private practices seem to fall between 8% and 12%. And then there’s not really good data on testing only practices that I can access.

I will say, in our practice, we have a pretty high Medicaid population, which is not in the top three factors related to no-shows, but it is number four or number five. [00:11:00] We have a pretty high Medicaid population and we run at about 12% no-show rate. That’s not just for testing. That includes therapy as well. So keep that in mind; mental health private practices seem to fall between 8% to 12%.

Okay. Let’s talk about some strategies for reducing no shows in no particular order. Actually, I’m going to put a little bit of order here.

The top strategy, not even going to bury the lead, I’m just going to give it to you right off the bat. The top strategy is text message confirmations. This showed up in study after study, anecdote after anecdote, and clickbait article after clickbait article, it’s consistent that text messaging is [00:12:00] going to help reduce your no-shows more than anything else.

The other highly rated interventions, so to speak, are all in the same ballpark. So appointment confirmation in general is going to go a long way toward reducing no-shows. Text messaging was at the top, confirmation phone calls or voicemails, and then the third option in that suite is calls from patient care coordinators.

Email is also included in that, but there is less data on email appointment reminders and whether they are helpful or not. So text messaging, confirmation voicemails or Robocalls, and then calls from care coordinators or a staff member. 

So if you do nothing else, automated text reminders are your best bet. Many EHRs, including our partner TherapyNotes, of course, offer automated text reminders. And I think it’s absolutely in your [00:13:00] best interest to just get that set up so that you are automatically texting your clients as long as they’ve consented, of course. Automatically texting your clients a reminder for the appointment.

Another factor that is related to no-shows or not no showing is whether the client can confirm their appointment. So if you’re doing text reminders and they have the capacity to text back a Y for yes to confirm, that’s a great predictor that they’re actually going to attend the appointment.

Let’s take a break to hear from a featured partner.

Y’all, there are so many EHRs out there to choose from. That’s why I am happy to endorse TherapyNotes as what I consider to be the best EHR for testing psychologists. The note templates are that are embedded are usable right out of the box for testing folks. We don’t have to do [00:14:00] any customization and that is so valuable.

Beyond that, TherapyNotes is a full-featured EHR. It handles scheduling, billing, insurance claim submission, notes, documentation, and everything. They also recently rolled out custom forms, which means that you can create your own intake paperwork to send to clients through their client portal. If you’d like to consider TherapyNotes, which I would highly encourage you to do, you can get two free months by going to thetestingpsychologist.com/therapynotes.

I’m excited to tell you about PAR’s all-new PAR Training Platform, an elevated online learning environment with everything you need in one place. This is the new home for PARtalks webinars, many of which offer APA and NASP-approved CEs and also houses on-demand learning tools and PAR product training [00:15:00] resources. Best of all, it is free, totally free. To learn more, visit parinc.com\resources\par-training.

All right, let’s get back to the podcast.

Okay. Now what are some other strategies that you could possibly use?

Thinking about one of my points from earlier, which is the modeling feature, there are plenty of models out there for predicting no shows and a model is useless without leading to some kind of action, right?

The vast majority of folks who are developing these models are using them to create a predictive overbooking system. They would suggest that you overbook your schedule to account for the number of no-shows that you’re going to have. And this is exactly the [00:16:00] strategy that we employ for our therapists. We did not use any kind of predictive model, but we did look at historical no-show rates for each of our therapists and then calculated an overbooking guideline to make sure that even if their historical average of clients cancel each week, they will still fall at or above their clinical hours quota for the week.

Again, not as relevant with testing, but I think there is something to be said for this strategy looking maybe across quarters or a six month period or even across the year. So if you go back and look at your data on no-shows for the past 12 to 24 months and you can get an average to figure out how many folks are going to no-shows over the course of that time period, then you maybe can take that and use that to overbook yourself a [00:17:00] little bit.

You want to be careful, of course, so you don’t get too far behind and get overwhelmed, but you can use that data to overbook yourself a bit. So if you know that 1 out of every 10 evaluations is going to no show or not follow through with the evaluation, and you do, let’s just say 50 evaluations a year, that’s one per week, then theoretically, you should overbook five evaluations somewhere along the course of the year. Maybe that’s one every couple months you do an extra one. So overbooking is a strategy that folks will often use, especially in larger practices.

Beyond text messaging and overbooking, what can we do?

Well, I think it’s a great idea to follow up with no-shows and offer self-scheduling. If you’re like me, [00:18:00] sometimes you don’t follow up with people who know show. Maybe you needed the extra time, man you don’t care that much, or it’s too much effort to reach out at that moment, or you don’t like talking on the phone, or you’re scared that they’re going to say that they just don’t want to come see you.

I get it. There are any number of reasons why you may not want to reach out right in that moment and check in with the person who’s no showing, right? Maybe you don’t want to embarrass them. Who knows? But following up is actually crucial if you care about filling that appointment. Again, people don’t purposefully no show most of the time. So a follow-up call is really helpful to check in with them. When you pair that with self-scheduling, it’s a nice one-two combination.

So you could follow up with a call and if you don’t catch them right at that moment to reschedule, you can say, I’m going to send you the link to self [00:19:00] schedule, to reschedule this appointment. All right? That gives them some flexibility and the capability to rebook the appointment whenever works for them.

Now, self-scheduling in general is tough with testing, I think, because a lot of us like to screen our appointments and make sure that we’re going to be a good fit. We also have a rigidly defined scheduling flow with intake and then testing and then feedback. So you can’t do self-scheduling across the board, but I think you can offer self rescheduling for intakes particularly. So if you have your intake spots pretty well defined on your calendar, you can always send someone your calendar link and say, hey, you can reschedule your intake for any of these open spots.

All right. What else? One thing that we found, and this showed up in my research as well, is [00:20:00] digital forms or digital paperwork are often a great proxy for appointment attendance. What does that mean? We found that if someone hasn’t completed their forms by the day before the appointment, the likelihood is very high that they will no show.

This matches the research as well. So If you have not converted over to digital paperwork in some form or fashion, I would highly recommend it both for convenience for the clients and ease of record keeping and not having to keep a bunch of paper records that you’ll later have to shred but for this extra reason of using digital forms as a proxy for attendance.

I don’t know what more to say on that other than to encourage you to consider some form of digital digital paperwork. There are many options to do this. Most of the EHRs include some form of digital paperwork, including again, our partner TherapyNotes, but many others, [00:21:00] and you can easily send paperwork through the client portal or worst case scenario email.

Other little tips that can help with no-shows. Those of you who are private pay and even some folks who take insurance have found a way to take a deposit. Taking a deposit and keeping a credit card on file are two great strategies from the financial side of things to reduce no-shows. If people know that their card is on file and that they’ve already paid a little bit for the appointment, then they presumably have more investment and are more likely to show up.

Now, that dovetails a little bit with no-show fees. So let me jump to that.

The research is pretty muddy here. I could not find much to say whether [00:22:00] charging no show fees works to get people to appointments more often. I’m guessing some of you may have heard of the principle of loss aversion. This is the idea that people are definitely more motivated by the possibility of losing money than by the possibility of earning money or gaining something. So that may come into play here on a basic level that people do not like to lose money and that might motivate them to attend their appointment.

But for me, the bigger underlying question or principle is whether people are willingly no showing, and if we’re going by the research, it would suggest that people are not willingly no showing. So then, no show fees are operating on the assumption that individuals can modify their behavior based on the no show fee or that the no show fee will influence their behavior. But as we talked about earlier, [00:23:00] purposeful no-shows aren’t that common. So I don’t know that implementing a behavioral intervention actually helps. It may help especially for recurring appointments or for therapy appointments. But it’s hard to say with this one-time situation with testing intakes.

So no show fees, a little muddy. We’re still going to do it. Don’t get me wrong, but I’m going to be taking a hard look at whether it is actually helpful or if there are other means of motivating folks to show up for their appointment.

Okay. Other strategies. Offer telehealth. People like telehealth. It is convenient. It is easy for populations that typically no-show to access appointments. Those populations are marginalized groups, younger age individuals, rural and poor clients, or low income clients. [00:24:00] Telehealth is convenient and it gives another option for folks if they are running into transportation issues, or scheduling crunches and whatnot. It’s just easy to do telehealth. So if you’re not offering telehealth in some form or fashion, I highly recommend it.

Again, many EHRs have telehealth built in. If you use Google Workspace, then Google Meet is HIPAA-compliant. You can use that for telehealth. Lots of options, but I would certainly consider it if you are not already.

Now, the last point I want to make is a more difficult one to chat about because it just doesn’t fit the model that most of us operate on. And that point is addressing the concern of appointments booking further out are more likely to result in a no-show.

So if [00:25:00] you have the flexibility to do this, and I’ll be honest, I don’t have a great template for how to do this. I do know at least one practice owner who operates on this model, but we haven’t been able to find a way to do it in a streamlined way. This is a model where you book people month by month rather than just booking out several months. Because as we said, the shorter wait time, the less likely clients are to no-show.

The research was pretty clear, at least in medical practices, that same-day appointments are preferable. I don’t think that that is at all doable in a testing practice. So I’m not advocating that. But can you get to a model where you are booking essentially a month at a time? So if you can keep your wait time to 30 days or less, that is going to make an appreciable difference, at least, according to the literature in terms of who is going to no-show and how many [00:26:00] people will no-show.

Again, I don’t have that built out and I don’t have a great model for that, but if you want to do some thinking and if anybody figures out a nice streamlined way to do a month-by-month booking system, I would love to hear about it. It will likely reduce your no shows.

All right. We covered a lot of ground here. So what are the takeaways?

The takeaways are no shows are pretty common. The biggest factor for predicting no-shows was previous no-shows. Again, this is hard in testing because we don’t typically have repeat customers, but other factors include whether the patient confirmed their appointment and or filled out their paperwork; age; 21 to 30-year-olds are the highest likelihood of no-shows; and insurance, Medicaid clients had a higher likelihood of no showing than other demographic variables.

[00:27:00] What to do. Texting was the most helpful in reducing no-shows, especially if you can get an appointment confirmation in return. And lastly, no-show fees and their effectiveness are uncertain at best. More research needs to be done there.

I hope that this is helpful to take a little bit of a science-based or evidence-based look at no-shows. As always, if I missed anything or if anyone is doing research in this area, I would love to hear from you and help us all continue to reduce these no-shows.

All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes. So make sure to check those out.

[00:28:00] If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development: beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.

[00:29:06] The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice. Diagnosis or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with an expertise that fits your needs.​

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