How to Reduce No-shows to Virtual Appointments

Todd Molfenter, Ph.D.
Director, Great Lakes ATTC, MHTTC, and PTTC

Is this a familiar scenario for your organization?

Day 1: Stay-at-home order: Your agency enacts social distancing guidelines.

Day 3: Your agency has switched in-person counseling to telephonic or video-based counseling.

Day 12: Virtual services, particularly telephone, have increased engagement rates!

Day 30: The honeymoon is over: show rates to virtual appointments are decreasing, especially among new consumers.

In the COVID-19 era, an old nemesis has returned: appointment no-shows. While telehealth has removed some barriers to behavioral health services, other engagement challenges are emerging. Agencies can take the “how exactly are we going to do this?” approach that COVID-19 has thrust us into since the beginning.

Another way is to turn to existing tools and proven practices to address the new no-show dilemma.

Three Tips to Reducing No-Shows During COVID-19 and Beyond
Apply these three tips, in this order, and watch your no-show rates decrease and show-rates increase.

1. Track No-Show Performance 

You can’t improve what you do not measure. No-shows should be measured. Measure no-shows to virtual appointments the same way you measured no-shows to in-person appointments before COVID-19. Compare no-show rates pre- and post- COVID. Segment the data as needed: new vs. existing client; by client age; by appointment type, etc. This measurement creates a foundation for improvement.

2. Use PDSA Cycles!

The Plan-Do-Study-Act (PDSA) method creates a simple process to test new approaches and observe their impact on no-shows. (See related post from NIATx coach Mat Roosa: Learning from Crisis: PDSA in Times of Challenge.) Plan a change; Do a change; Study the impact of the no-shows; then, Act on the change. (Adopt, adapt, or abandon.) You can conduct PDSA Cycles as part of an organized agency-based improvement initiative. Or, individual clinicians can perform PDSA cycles to improve their show rates.

What are good practices for addressing no-shows in a PDSA cycle? See Tip 3:

3. Use Proven Practices to Reduce No-shows
While COVID-19 provides us with some very new situations, we can learn a lot from what’s worked in the past to reduce no-shows.

Open scheduling: Book appointments to accommodate consumers’ schedules. Evening hours? Weekend hours? Ask the consumer, “When would you like us to talk next?”

Reminder calls, e-mails, and text messaging work for virtual appointments as well as they do for in-person appointments. Note the scheduling of the reminder message or text: Two days prior seems to work best for in-person appointments; one day before or on the day of for virtual appointments.

Evidence-Based Practices to Reduce No-Shows

Use Motivational Interviewing (MI) to reduce no-shows by increasing the consumer’s interest in coming back. The growing evidence base for MI shows its effectiveness in a variety of settings.

Use incentives or Contingency Management. Contingency Management is proving to be an effective EBP to enhance retention, particularly for stimulant use disorders. Offer consumers an incentive to reward attendance: a recognition certificate, gift card, or other small prizes.

Learn more about Motivational Interviewing and Contingency Management through the free online courses available through HealtheKnowledge, the ATTC Network’s online learning portal.

Patient no-show trend analysis can identify high-risk no-show patient categories (new vs. existing patients, payer source, patient age) as well as situations (day of the week, time of day, location). Develop patient scheduling practices to increase show rates from identified areas. This practice is particularly relevant as we need to understand better when, where, and how virtual appointments have greater participation.

Interested in learning more about how you can use these tips to reduce no-shows in your organization? Watch for information on the new Virtual NIATx Change Leader Academy—details available soon on the Great Lakes ATTC, MHTTC, and PTTC websites.

What have you found most useful in increasing participation in virtual care? What conditions and practices hurt appointment attendance? What have helped? Let us know in the comment section below.

Dr. Todd Molfenter is the deputy director of the Center for Health Enhancement Systems Studies at the UW-Madison. He is also the director of three SAMHSA-funded Technology Transfer Centers: the Great Lakes Addiction Technology Transfer Center, Mental Health Technology Transfer Center, and Prevention Technology Transfer Center. Todd specializes in implementation science, with a particular focus on technology and evidence-based practices in behavioral health.

South Southwest ATTC: Implementing Remote Technology In a Time of Crisis

Maureen Nichols
Director, South Southwest Addiction Technology Transfer Center
HHS Region 6

The recent COVID-19 health pandemic has accelerated the implementation of behavioral health services via remote technology, including telephone and video conferencing. In March 2020, as behavioral health treatment and recovery organizations prepared to continue critical services while implementing social distancing guidelines needed to keep patients and staff safe and healthy, many turned to the use of technology as a solution, including video conferencing and telephone services. For organizational leadership, decisions around critical issues such as compliance with laws and best practices related to patient confidentiality and protection, choice of platforms, licensing and certification regulations for practitioners, and costs and reimbursement procedures, had to be made at an accelerated rate. Federal and state agencies began issuing guidance related to relaxation of enforcement of privacy protections in a limited way due to the short-term health crisis, and funders addressed modifications to reimbursement policies to include telehealth services. However, much of the guidance was necessarily high level, leaving leadership of individual behavioral health programs to assess the fiscal and practical ramifications of responding to the new service landscape via the use of telehealth in the both the short and long term.


Over the past several years, the South Southwest Addiction Technology Transfer Center, in partnership with National Frontier and Rural Telehealth Education Center (NFARtec), has been offering training and technical assistance to states, tribal communities and behavioral health organizations and practitioners as part of its telehealth initiative. This includes documenting best practices and real world examples of implementation, such as the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) successful initiative to increase the uptake of telehealth technologies to deliver assessment, treatment and recovery services in their public health system. It also includes offering behavioral health clinicians and peer support specialists learning collaborative opportunities to build and practice their videoconferencing skills and receive coaching and feedback from experienced behavioral health telehealth practitioners.


At the start of the response to the pandemic, South Southwest ATTC began receiving multiple requests from organizations across the region for immediate guidance on how to translate many of the strategies for remote technology on the ground in a rapid and timely manner. SSW ATTC facilitated regional dialogues between state and local behavioral health organizations with telehealth experience and organizations new to the use of remote technology, including an event in Oklahoma with tribal communities, experienced behavioral health providers and ODMHSAS. Through those discussions, it became apparent that concrete guidance on practical steps for organizations to take in order to implement remote technology was needed. As a result, SSW ATTC developed the Framework for Implementation of Telehealth Services in a Behavioral Health Setting in a Short Time Frame, which covers topics that include:

• Determining participant interest and capacity for use of technology
• Selection of technology platforms
• Patient safety and privacy considerations
• Staff support and training
• Review of internal policy and procedures
• Adapting work flows
• Fiscal considerations and reimbursements

The goal is to provide a framework for behavioral health care providers that guides organizational leadership through short term practical steps for implementation of remote services via technology while including successful long-term strategies for sustaining telehealth services.

This guide is one piece of a regional and national TTC network partnership designed to provide resources and support to the behavioral health field to ensure services to individuals in our community are accessible, evidence based and culturally responsive during the current challenging health crisis and beyond. Additional resources from the TTC network are available at attcnetwork.org, mhttcnetwork.org and pttcnetwork.org. To access regional assistance from the South Southwest Addiction Technology Transfer Center, please contact us via website or email.

Share Your Perspectives about Opioid Use Disorder among People with Disabilities from Minority Backgrounds

Share Your Perspectives about Opioid Use Disorder among People with Disabilities from Minority Backgrounds.Please click or cut and paste survey link below to participate:

https://www.psychdata.com/s.asp?SID=189204

We are pleased to invite substance, mental health service and vocational rehabilitation professionals (e.g., counselors, clinicians, directors) from across the country that provide to participate in a national study on Opioid Use Disorder Impacts on Employment Prospects for People with Disabilities from minority backgrounds (i.e., African American, Hispanic or Latino, American Indian, Alaskan Native, or Native Hawaiian or other Pacific Islanders). Opioid use disorder (OUD) can involve maladaptive/misuse of prescribed opioid medications, use of diverted opioid medications, or use of illicitly obtained heroin.

This study is being conducted by The Langston University Rehabilitation Research and Training Center (LU-RRTC) on Research and Capacity Building for Minority Entities. Langston University is the only historically black college or university (HBCU). The LU-RRTC is funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).

The new information generated through this study would provide insights on how policy makers, educators and federal research sponsoring agencies such as the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and the National Institutes of Health (NIH) can better respond to the needs of people with opioid use disorder, especially people with disabilities from minority backgrounds. In addition, the study findings may be used as a foundation for developing interventions that seek to improve the experiences and outcomes of individuals with disabilities from minority backgrounds with opioid use disorder.

The information in this study will be used only for research purposes and in ways that will not reveal who you are. Study participants will not be identified in any publication from this study. The survey will take around 20 minutes to complete. If you have any questions or concerns, please contact Dr. Corey Moore (Principal Investigator) via email: corey.moore@langston.edu or Dr. Edward Manyibe (Co-PI) via email: manyibe@langston.edu. If you experience technical difficulty with the survey, contact Dr. Andre Washington: andre.washington@langston.edu and he will be happy to assist you.

Please click or cut and paste survey link below to participate:

https://www.psychdata.com/s.asp?SID=189204

Thank you in advance for your contribution.

How social isolation, loneliness, and insecurity affect people in recovery from addiction and mental illness during COVID-19; and what to do about it

By Pierluigi Mancini, Ph.D.
Project Director, National Hispanic and Latino ATTC

We are going through a difficult period, together, and we are all going through it in our own way. What COVID-19 has done to us as a society is traumatic and the impact of untreated trauma can be subtle, insidious, or outright destructive.

The American Psychiatric Association (APA www.psychiatry.org) reported in a recent survey that almost half of Americans (48%) are anxious about the possibility of contracting coronavirus, COVID-19, that 40% are anxious to get seriously ill or die, and 62% are anxious about the possibility of family and loved ones becoming infected.

It is natural to feel stress, anxiety, anguish and worry during and after a crisis like COVID-19. Each person reacts differently, and their own feelings will change over time. You have to become aware of how you feel and accept it.

Separation from loved ones, loss of freedom, and uncertainty about the state of the disease are cause for concern. Studies have begun to show that most people in social isolation have negative psychological effects, including symptoms of post-traumatic stress, confusion, and anger. The biggest stressors include fears of infection, frustration, boredom, inadequate supplies, inadequate information, financial losses, and stigma.

Lack of connection can cause a feeling of loneliness and is especially aggravated in those recovering from addictions or mental health problems. Each one reacts differently to stressful situations. The typical reactions that occur when sheltering in place due to an immediate problem are different. Some of the emotions that we may be feeling in this situation include anxiety, fear, worry, uncertainty, frustration, sadness, boredom, fear of asking for income or work and negative effects on the ability to sleep well and eat healthy.

The fact of not being able to continue with the routine itself is a factor that disorganizes our structure since we lose the feeling of control. It is important to remember the ability we have to reorganize a new structure.

We can also go through different changes including changes in behavior such as the increase or decrease in energy and activity levels or excessive worry and even the inability to feel pleasure or have fun.

Changes in your body such as stomach pain or headaches or other discomforts or loss or increase in appetite; changes in thoughts like difficulty remembering things or feeling confused. All these symptoms can be interpreted as excuses or reasons to drink or use drugs or to give up and not want to go on.

If the madness of addiction is lived in solitude during its last stages, recovery always occurs with the help and participation of others. And for that we need to build resilience.

The American Psychological Association (https://www.apa.org/topics/resilience) defines resilience as "adaptation to adversity, trauma, tragedy, threats, or major sources of stress."

The concept of resilience helps to understand and promote positive development in situations originally perceived as negative and in potentially destructive challenges. It is the ability to respond to pressures and tragedies quickly, adaptively and effectively, remembering and acknowledging that experience to face future adversities. Applied to humans, resilience is the ability of an individual to develop positively despite adversity. Their goal is to come out strengthened and transformed by the experience, however painful it may be.

We can build resilience using various tools such as focusing on one's strengths, rather than weaknesses; acting on the solutions, and not on the causes of the problem; substituting rigidity for flexibility and recognizing that the past cannot be changed, but that we can learn how it is influencing our present to make the appropriate adjustments today.

For those in social isolation, the general recommendation is to establish a routine with space for leisure and exercise; stay informed through official trustworthy channels like the CDC (www.cdc.gov) and SAMHSA (www.samhsa.gov) and do not overexpose yourself to the news about the coronavirus. It is also recommended to keep in touch with family and friends. It is important to stay connected through social media, but again, with limits. Connections, even if they are virtual, are the great shock absorbers of stress.

We must trust our recovery. What we have achieved so far is worth a lot and you should not forget everything you have done to achieve it. Use your tools, just because you can't go out you don't have to forget them. And in order to relax, start with things you know that help you relax, such as deep breathing, stretching, meditating or praying, or entertaining yourself with a hobby you like.

Do things you enjoy, like reading, listening to music, exercising, or taking a bath; talk about your experience and feelings with loved ones and friends; keep hope and think positively.

And finally, if you need help, please find her. Today we have help available and you can go to www.samhsa.gov where you will find support phones and websites.

[A webinar of this same title is available on our page in English, Spanish and Portuguese. Please visit https://attcnetwork.org/centers/national-hispanic-and-latino-attc/home]



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Cómo el aislamiento social, la soledad, y la inseguridad afecta a las personas en recuperación de adicción y salud mental durante COVID-19; y que hacer al respecto

Por Pierluigi Mancini PhD
Director del Centro Hispano Latino de Capacitación y Asistencia Técnica en Adicción

Estamos pasando por un momento realmente difícil, juntos, y todos lo estamos pasando en nuestra propia manera. Lo que el COVID-19 nos ha hecho como sociedad es traumático y el impacto del trauma que no es tratado puede ser sutil, insidioso o totalmente destructivo.

La Asociación Americana de Psiquiatría (APA www.psychiatry.org) informó en una encuesta reciente que casi la mitad de los estadounidenses (48%) están ansiosos por la posibilidad de contraer coronavirus, COVID-19, que el 40% está ansioso por enfermarse gravemente o morir, y que el 62% está ansioso por la posibilidad de que la familia y los seres queridos se infecten.

Es natural sentir estrés, ansiedad, angustia y preocupación durante y después de una crisis como el COVID-19. Cada persona reacciona de manera diferente y sus propios sentimientos cambiarán a lo largo del tiempo. Hay que tomar conciencia de cómo uno se siente y aceptarlo.

La separación de los seres queridos, la pérdida de libertad, y la incertidumbre sobre el estado de la enfermedad son causantes de preocupación. Estudios han comenzado a demonstrar que la mayoría de las personas que se encuentran en aislamiento social registran efectos psicológicos negativos, incluidos síntomas de estrés postraumático, confusión y enojo. Los mayores factores estresantes incluyen temores de infección, frustración, aburrimiento, suministros inadecuados, información inadecuada, pérdidas financieras y estigma.

La falta de vinculación puede provocar una sensación de soledad y agravarse especialmente en aquellas personas en recuperación de adicciones o de problemas de salud mental. Cada uno reacciona de forma diferente ante situaciones estresantes. Son diferentes las reacciones típicas que ocurren cuando hay que refugiarse en sitio debido a un problema inmediato. Algunas de las emociones que podemos estar sintiendo ante esta situación incluyen la ansiedad, el miedo, la preocupación, le incertidumbre, la frustración, la tristeza, el aburrimiento, temor por pedida de ingresos o trabajo y efectos negativos en la habilidad de dormir bien y comer saludablemente.

El hecho de no poder continuar con la propia rutina es un factor que desorganiza nuestra estructura ya que perdemos la sensación de control. Es importante recordar la capacidad que tenemos para reorganizar una nueva estructura.

También podemos pasar por diferentes cambios incluyendo cambios en conducta como el aumento o disminución en sus niveles de energía y de actividad o la preocupación excesiva y hasta la incapacidad de sentir placer o divertirse. Cambios en su cuerpo como el dolor de estómago o dolores de cabeza u otras molestias o la pérdida o aumento de apetito; cambios en sus pensamientos como la dificultad para acordarse de cosas o el sentirse confundido. Todos estos síntomas pueden ser interpretados como excusas o razones para beber o usar drogas o para rendirse y no querer seguir adelante.

Si la locura de la adicción se vive en soledad durante sus últimas etapas, la recuperación siempre ocurre con la ayuda y la participación de otros. Y para eso necesitamos construir la resiliencia.

La Asociación Psicológica Americana (https://www.apa.org/topics/resilience) define resiliencia como ‘la adaptación ante la adversidad, el trauma, la tragedia, las amenazas o las fuentes importantes de estrés.’

El concepto de resiliencia ayuda a entender y promover el desarrollo positivo en situaciones percibidas originalmente como negativas y en retos potencialmente destructivos. Es la capacidad de responder a presiones y tragedias rápida, adaptativa y efectivamente, recordando y reconociendo dicha experiencia para enfrentar futuras adversidades. Aplicado a los seres humanos, la resiliencia es la capacidad que tiene un individuo de desarrollarse positivamente a pesar de las adversidades. Su objetivo es salir fortalecidos y transformados por la experiencia, por más dolorosa que pudiera resultar.

Podemos construir la resiliencia utilizando varias herramientas como enfocándonos en las propias fortalezas, en vez de las debilidades; actuando sobre las soluciones, y no sobre las causas del problema; sustituyendo la rigidez por la flexibilidad y reconociendo que el pasado no puede ser cambiado, pero que sí podemos aprender cómo está influenciando en nuestro presente para hacer hoy los ajustes convenientes.

Para quienes están en aislamiento social, la recomendación general es establecer una rutina con espacio para el ocio y el ejercicio; informarse por canales oficiales como el CDC (www.cdc.gov) y SAMHSA (www.samhsa.gov) y no sobreexponerse a las noticias sobre el coronavirus. También se recomienda mantener el contacto con familia y amigos. Es importante permanecer conectados a través de redes sociales, pero de nuevo, con límites. Los vínculos, aunque sean virtuales son el gran amortiguador del estrés.

Tenemos que confiar en nuestra recuperación. Lo que hemos logrado hasta hoy vale mucho y no debes olvidar todo lo que has hecho para realizarlo. Utiliza tus herramientas, solo porque no puedes salir no tienes que olvidarlas. Y para relajarnos, comience con cosas que sabes que te ayudan a relajarte, como el respirar profundo, meditar o rezar, o entretenerse con un pasatiempo que le agrade.

Haga cosas que disfruta, como leer, escuchar música, hacer ejercicio o darse un baño; hable sobre su experiencia y sus sentimientos con sus seres queridos y sus amigos; mantenga la esperanza y piense positivamente.

Y finalmente, si necesita ayuda, por favor búsquela. Hoy tenemos ayuda disponible y puedes visitar www.samhsa.gov donde encontraras teléfonos y sitios web de apoyo.

[Un seminario web de este mismo título está disponible en nuestra página en inglés, español y portugués. Por favor visite https://attcnetwork.org/centers/national-hispanic-and-latino-attc/home]


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Como o isolamento social, a solidão e a insegurança afetam as pessoas em recuperação de transtornos por uso de substâncias e distúrbios mentais durante o COVID-19; e o que fazer sobre isso

Por Pierluigi Mancini, Ph.D.
Diretor de Projeto, Centro Hispânico -Latino de Treinamento e Assistência Técnica em Abuso de Substâncias (NHL-ATTC)

Estamos passando por um período difícil, juntos, e todos estamos lidando com isso à nossa maneira. O que o COVID-19 nos causou como sociedade é traumático e o impacto de traumas não-tratados pode ser sútil, insidioso ou totalmente destrutivo.

A Associação Americana de Psiquiatria (APA) www.psychiatry.org relatou em uma pesquisa recente que quase metade dos americanos (48%) estão preocupados com a possibilidade de contrair o coronavírus, 40% estão preocupados em ficar gravemente doente ou morrer e 62% estão preocupados com a possibilidade de ter a família e os entes queridos infectados.

É natural sentir estresse, ansiedade, angústia e preocupação durante e após uma crise como o COVID-19. Cada pessoa reage de maneira diferente e os sentimentos mudam com o tempo. Você precisa se tornar consciente de como você se sente e aceitar.

A separação dos entes queridos, a perda da liberdade e a incerteza sobre o estado da doença são motivo de preocupação. Estudos começaram a mostrar que a maioria das pessoas que estão em isolamento social relata efeitos psicológicos negativos, incluindo sintomas de estresse pós-traumático, confusão e raiva. Os maiores estressores incluem o medo de infecção, receio de perder o emprego, frustração, tédio, suprimentos inadequados, informações inadequadas, perdas financeiras e estigma.

A falta de conexão pode causar uma sensação de solidão e é especialmente agravada naqueles que se recuperam de transtornos por uso de substâncias e distúrbios mentais. Cada um reage de maneira diferente a situações estressantes. As reações típicas que ocorrem quando existe a orientação de ficar em casa durante um determinado período, por conta de um problema imediato são diferentes. Algumas das emoções que podemos sentir nessa situação incluem ansiedade, medo, preocupação, incerteza, frustração, tristeza, tédio, medo de não ter renda ou trabalho e efeitos negativos na capacidade de dormir bem e comer de forma saudável.

O fato de não podermos continuar com a rotina em si é um fator que desorganiza nossa estrutura, pois perdemos a sensação de controle. É importante lembrar a habilidade que temos de reorganizar uma nova estrutura.

Também podemos passar por diferentes mudanças, incluindo mudanças no comportamento, como aumento ou diminuição dos níveis de energia e atividade, ou preocupação excessiva e até a incapacidade de sentir prazer ou se divertir.

Alterações no seu corpo, como dores de estômago, dores de cabeça, outros desconfortos ou perda ou aumento do apetite; mudanças nos pensamentos, como dificuldade em lembrar as coisas ou se sentir confuso. Todos esses sintomas podem ser interpretados como desculpas ou razões para beber ou usar drogas ou para desistir e não querer continuar.

Se a loucura por conta do uso de substâncias é vivida em solidão durante seus últimos estágios, a recuperação sempre ocorre com a ajuda e participação de outras pessoas. E para isso, precisamos construir resiliência.

A Associação Americana de Psiquiatria (https://www.apa.org/topics/resilience) define resiliência como "adaptação a adversidades, traumas, tragédias, ameaças ou principais fontes de estresse".

O conceito de resiliência ajuda a entender e promover o desenvolvimento positivo em situações originalmente identificadas como negativas e em desafios potencialmente destrutivos. É a capacidade de responder a pressões e tragédias de forma rápida, adaptativa e eficaz, lembrando e reconhecendo essa experiência para enfrentar adversidades futuras. Aplicada aos seres humanos, a resiliência é a capacidade de um indivíduo se desenvolver positivamente, apesar das adversidades. Seu objetivo é sair fortalecido e transformado pela experiência, por mais dolorosa que seja.

Podemos construir resiliência usando várias ferramentas como focar nos nossos pontos fortes, e não nas nossas fraquezas; atuar nas soluções, e não nas causas do problema; substituir rigidez por flexibilidade e reconhecer que o passado não pode ser mudado, mas que podemos aprender como ele está influenciando nosso presente para fazer os ajustes apropriados hoje.

Para quem está em isolamento social, a recomendação geral é estabelecer uma rotina com espaço para lazer e exercício; mantenha-se informado através de canais oficiais confiáveis como o CDC (www.cdc.gov) e SAMHSA (www.samhsa.gov) e não se exponha demais às notícias sobre o coronavírus. Também é recomendável manter contato com familiares e amigos. É importante manter-se conectado através da mídia social, mas novamente, com limites. As conexões, mesmo que sejam virtuais, são os grandes amortecedores do estresse.

Devemos confiar em nossa recuperação. O que alcançamos até agora é muito valioso e você não deve esquecer tudo o que fez para chegar até aqui. Use suas ferramentas, só porque você não pode sair, não precisa esquecê-las. E, para relaxar, comece com coisas que você sabe que te ajudam a relaxar, como respiração profunda, alongamento, meditação ou oração, ou mantendo-se ocupado com um hobby que você gosta.

Faça coisas que você goste, como ler, ouvir música, se exercitar ou tomar um banho; fale sobre sua experiência e sentimentos com entes queridos e amigos; mantenha a esperança e pense positivamente.

E, finalmente, se precisar de ajuda, encontre-a. Hoje temos ajuda disponível e você pode acessar www.samhsa.gov para encontrar telefones e sites de apoio.

[Um seminário com esse mesmo título está disponível em nossa página em inglês, espanhol e português. Por favor visite https://attcnetwork.org/centers/national-hispanic-and-latino-attc/home]