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, 743749.

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.