Section 4. Scheduling

Broken Appointments

Broken appointments and cancellations are a fact of life for most dental practices. Down time negatively impacts productivity but can be minimized by maintaining a list of patients who have indicated they are available on short notice for appointments. If no patient can be reached to fill a broken appointment or cancellation, then the oral health professional can choose to spend more time providing services to the patients who do come or to complete paperwork and other administrative duties.

If the demand for services at your clinic exceeds your resources, causing you to limit the number of new patients accepted for care, then broken appointments will, in effect, deny access to other members of the community and waste the staff's time. Develop a written policy concerning broken appointments and present it to all patients at their first visit.

Many safety net dental clinics choose to not have a broken-appointment policy because of the barriers faced by some of their patients, including:

• No transportation, or need to rely on public transportation or others for transportation, or inclement weather impeding pedestrian travel.
• No phones.
• Problems finding someone to watch their children.
• Medical or behavioral health conditions that make daily life unpredictable.
• Unpredictable or inflexible work schedules.

Broken appointments, which also are known as failed appointments or "no shows," are one of the biggest problems that safety net dental clinics face.

Preventing Broken Appointments

Each of the following methods has been used with some success in safety net dental clinics throughout the country. Not all of the listed suggestions will be acceptable or will work everywhere. Each clinic should choose the combination of methods that works best for its particular circumstances.

• Develop an acceptable broken-appointment policy, and universally enforce it.
• Consider a signed contract with all patients that spells out their rights and responsibilities within the system, and enforce the contract.
• Consider having patients come in and complete all registration paperwork before their first appointment is scheduled. This investment of time may make it less likely that they will miss their exam appointment.
• Consider having parents complete an umbrella consent form for treatment of their children so that the parent need not be present at every appointment.
• Consider whether a community health worker is a good addition to your staff. This staff member can help ensure that barriers to attending appointments are reduced or eliminated by addressing individual situations, providing transportation vouchers, or finding other strategies.
• Confirm all appointments, including recall and hygiene appointments, two days before the appointment, or consider requiring patients to call in and confirm their own appointments the day before the visit or face losing the slot to someone else.
• After two or three (your clinic may choose the number) broken appointments within a calendar year, consider discharging the patient from the practice and allowing him or her to be seen for emergencies only. While no one likes to dismiss a patient from the practice, because doing so goes against the reasons the clinic was established, patients with multiple broken appointments cannot be allowed to jeopardize the sustainability of the program for all other patients. At the end of the penalty year, the patient can be invited back for comprehensive care if he or she desires. Another alternative to outright dismissal is to place the patient on same-day-only status. This means that the patient must call the clinic on the day they he or she would like to be seen, and if there is an opening in the schedule, he or she will be seen. Otherwise, the patient will be advised to call back the next time he or she is available to come in. Of course, in an emergency, every effort will be made to see the patient that day.
• Problem-focused patients, episodic users, and emergency patients tend to have a higher broken-appointment rate than other patients of record attending comprehensive care, especially when definitive care cannot be provided at their initial emergent visit. Broken appointments can be prevented by asking these patients to call in a day or two after their emergency visit to let the clinic know how they are doing and to schedule an appointment. Those who want care will call, and those who only wanted palliative treatment for their immediate problem (and are more likely to break an appointment for definitive care that they didn’t seek in the first place) will not call.
• A safety net dental clinic in Massachusetts has achieved some success in reducing broken appointments by requiring patients to write a letter to the clinic director detailing why they missed an appointment and why they should be let back into the appointment system.
• If possible, use case-management and social services to coordinate visits to the facility so that patients may be able to visit other health professionals on a given day instead of just oral health professionals. For example, it may be helpful for a family to attend both a well check and a dental visit for a child on the same date vs. coming in for two separate visits.

Compensating for Broken Appointments

• Maintain a short-notice call list, and use it to fill gaps in the appointment schedule.
• Double-book patients who have a history of broken appointments. It works best if the extra appointment is for a simple procedure such as an exam, in order to provide flexibility in case both patients appear for their appointments. Double booking should probably be considered a last resort, because a busy schedule can be thrown into chaos when all of the patients show up.
• Medicaid patients are the only patients who have no out-of-pocket expenses and do not require pre-authorization for routine restorative care. This means that if a Medicaid patient is in the chair, and another patient fails to show, more services can be provided to the patient who is present without any financial impact on the patient.
• Every effort should be made to ensure that whenever a sliding-fee-scale patient is scheduled for restorative care, a Medicaid or commercially insured patient is scheduled during the same or preceding time block to facilitate sustainability of the program.
• Emergent patients can be invited to fill broken appointments but should be scheduled opposite a simple procedure so that definitive care can be provided whenever possible.
• Complete basic preventive and restorative services (phase I care) first in the treatment plan, before providing more complex treatment such as RCTs, crowns, bridges, and removable prosthetics. Many patients who miss appointments, especially episodic users, will do so early in the treatment plan, and exams and basic services are by nature less time consuming than complex services. Patients who do not value their appointments should not be scheduled for expensive, elective service.