Improving No-Show Rates at the Northridge

Nutrition Counseling Center

Rebecca Heming, Dietetic Intern

University of Virginia Health System

Preceptors: Angela Hasemann Bayliss MS, RDN, CSP and Austin Shelly, RD

May 1st, 2019

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ABSTRACT

No-shows, or patients who fail to arrive to their appointment and do not call ahead of

time to reschedule or cancel, are a common and costly problem for dietitians. Despite this, there

is minimal research in the field of dietetics addressing this issue. Numerous factors contribute to

patients missing their appointments, including demographics, lead time, insurance, and

forgetfulness. A wide variety of tactics exist that dietitians can utilize to decrease no-show rates

which are broadly broken down into logistical strategies, financial strategies, and dietitian

specific skills. The purpose of this project is to analyze key factors contributing to no-show rates

at the Nutrition Counseling Center (NCC) at Northridge to determine interventions that would

effectively improve no-show rates. Historical data, provider feedback, and industry best practices

were utilized to develop target areas for improvement.

LITERATURE REVIEW

No-Show Rates

No-shows are a common problem for dietitians, especially those working in outpatient or

private practice settings. For the purposes of this paper, a no-show is defined as a patient who

does not arrive for their appointment and does not call ahead of time to cancel or reschedule.

Despite a steady decline since 1981 in no-show rates across all types of medical appointments in

every continent from an average of approximately 25% to 15%1, no-shows continue to pose a

variety of problems for both dietitians and their patients. The adverse effects of no-shows include

loss of revenue and a resultant increase in healthcare costs, increased wait times, staffing issues,

decreased access to care, and reduced clinic efficiency.2,3 Furthermore, patients are more likely

to have worse outcomes due to lack of continuity of care, reinforcement, and individualization of
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treatment .2,3 This project will address the high no-show rate at the Northridge Nutrition

Counseling Center (NCC) in Charlottesville, Virginia and provide dietitians with strategies they

can implement in their own workplace.

No-show rates, which are calculated by dividing the number of missed appointments over

the total number of scheduled appointments, vary drastically between different practices.

Regardless of the type of health clinic, no-shows are ubiquitous, although certain medical

specialties seem to fair better than others. An ophthalmology clinic at the University of Virginia

Health System (UVAHS) analyzed 51,529 appointments and found an average no-show rate of

21.7% for their resident clinic and 6.6% for their faculty clinic.3 Brigham and Women's hospital

colposcopy clinic discovered that of the 4,199 women who came to the clinic between January

2006 and December 2013, 58% of them had missed at least one appointment.4 Of 163,554

appointments scheduled at an urban academic internal medicine clinic with an underserved

outpatient population, 45% were missed between January 2008 and June 2011.5 Finally, a

systematic literature review of 105 studies from a wide variety of medical specialties determined

that the average no-show rate was 23%.1 Intravenous clinics had the lowest no-show rate, with

some reporting just 4%, while physiotherapy clinics had up to a 79.2% no-show rate.1 Dietitians

at three major hospital clinics, Brigham and Women’s, Cleveland Clinic, and Johns Hopkins

Bayview Medical Center, were emailed to collect data and reported no-show rates of 13.15%,

24%, and 22% respectively (Austin Shelly, RD, email communication, February 2018). Little

other data exists of no-show rates specific to dietitians, which makes it a challenge to make

comparisons and compile best practices.

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Factors Influencing No-Show Rates

Numerous studies have been done to try to determine which patients are more likely to

miss appointments and elucidate why they do not come. A complex variety of factors contribute

to patients missing their appointments, including age, race, length of time from scheduled

appointment, previous missed appointments, lower socio-economic status, and distance.1,2,6

Demographics A systematic review found that minorities, specifically Hispanic and African-

Americans, were more likely to miss appointments than other races.1 Younger adults are more

likely to be no-shows, although the exact age when this begins to improve is unclear.1,9 Marital

status does not appear to be a significant factor, though some studies suggest that married parents

are less likely to miss appointments.1 Education also does not appear to be a significant factor;

however, one study reported that having any formal education decreased the likelihood of

missing an appointment by 30% and the incidence decreased by 60% with a college degree.1

Some studies found that men were more likely to miss appointments than women; however,

overall gender is not a major contributor to the no-show rate.1

Clinic Specifics How long patients must wait for an appointment appears to have a large impact

on the no-show rate. Most studies have found that lead time, defined as the number of days

between when an appointment was scheduled to the time the appointment actually took place,

had the biggest impact on no-show rates. An increase in lead time led to a corresponding

increase in the no-show rate.1 A study found that in outpatient mental health settings, reducing

wait times for an appointment from 13 days to 0 days created a 34% reduction in missed

appointments.8 UVAHS experienced a 29.2% jump in their no-show rate in their resident
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ophthalmology clinic when appointment wait times increased from 2 weeks to 6 months.3 A

study of six outpatient substance abuse clinics found that by adding capacity, they were able to

decrease their no show rates by an average of 24.3%.8 Strategies to achieve this varied among the

clinics but included creating new types of groups (e.g. pretreatment groups), adding additional

appointment slots, and adding new times for group sessions.8 Eleven outpatient substance abuse

clinics decreased their waiting times and achieved an average reduction of 20.2%.8 Walk-in

appointments, double booked appointments, and centralized appointment scheduling were used,

with the most common strategy being adding walk in appointment times.8 In this study, wait

times had to be reduced by at least 10% for the no-show rate to decrease.8 Aside from these

strategies, dietitians may be able to decrease wait times for appointments and no-show rates by

tailoring the duration and follow up timeline to the individual patient to create more space in the

schedule .2

More experienced providers have lower no-show rates, and patients who were referred by

another provider had a lower risk of missing their appointments as opposed to patients who

scheduled the appointments without receiving a referral.1 Most studies found the type of visit to

be significant, but there was a discrepancy between whether no-show rates were higher for new

visits or follow ups.1 A directly proportional effect has been observed between the no-show rate

and distance to the clinic, meaning that patients who have to travel farther are less likely to show

up.1 Overall, day of week, month, and appointment time were generally not significant factors in

most studies, although some studies have reported highest no-show rates on Mondays.1
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Patient Specifics Research has shown that patients who are on government assistance are more

likely to miss appointments. Conversely, patients who were insured, especially through private

insurance, were less likely to miss appointments.1,7 Further, any previously missed appointments

increased the likelihood of a no-show; however, it is unclear how many prior missed

appointments impacted this.1

Patients who feel fearful, anxious, or not respected are more likely to no-show.6,7 In

addition, patients who reported that they felt better or worse (e.g. an improvement in symptoms

or worsened symptoms) were less likely to come to their appointments.7,9 Medical history,

diagnosis, and medication may also be factors to consider. For example, HIV patients are less

likely to miss appointments, whereas those with depression are more likely to no-show.1 Patients

with medical issues such as low blood sugar, coronary artery disease, and psychiatric

disturbances have increased no-show rates.1 Those who are on anti-depressants, psychiatric

medications, or struggle with substance abuse are also less likely to show up to their

appointments.1 Psychosocial problems also increase the risk of a no-show.1

Dietitian Specifics When asked by researchers, patients have given a wide variety of reasons for

missing appointments. These include forgetting about the appointment, losing the appointment

card, coming on the wrong day, and lacking money or transportation.2,6-7

In a study of 293 patients with diabetes at an outpatient university hospital, 73% admitted

to being hesitant to go to the dietitian. Of those, 51 participants gave explanations with 43.2%

stating they were reluctant to visit a dietitian because their weight had remained stable.10 Patients
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who had lower risk perceptions of their diabetes and lower self-efficacy were less likely to come

to their appointments.10 Of the respondents, 11.8% felt that the advice given by the dietitian did

not work, so they did not want to return.10 Other reasons given for reluctance to attend

appointments included the distance being too far, the appointments being “too big of a hassle”,

not wanting to be treated like a child, having too high blood sugars, feeling like they knew

everything the dietitian told them, getting a different dietitian at each visit, and feeling like the

dietitian wanted them to make too many changes.10 These responses highlight the need to treat

patients with respect and to individualize counseling as much as possible.

Of the patients who missed their appointments, 43.7% said they forgot.10 Patients coming

on the wrong day and the dietitian telling them nothing new each made up 11.7% of missed

appointments.10 Less common reasons given were not knowing why they did not attend, being

away on a trip, not having time, oversleeping, their weight not changing, being changed to a

different dietitian, feeling as though the advice was not working, and the visit to the dietitian

being rated as the least important when going to the hospital.10 Based on this, creating effective

reminders for patients to come to their appointments seems to be the single biggest way to reduce

no-show rates.

Strategies to Improve No-Show Rates

Logistics

Reminders A nearly universal strategy, reminders may include physical reminder cards,

telephone calls, letters, emails, and text messages. A nutrition clinic at a community hospital was

able to make a 7% reduction in their no-show rate by using an automated telephone service to
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call patients 1-2 days prior to their appointment as a reminder.2 It is possible that having staff

make personal phone calls would create an even larger reduction.13 Other studies that

implemented reminder phone calls in general health clinics have seen reduction rates from an

average of 23.1% to 13.6% of patients missing appointments.8 Use of text message reminders

was explored by several studies. Interestingly, the first study found that those who did not get

text reminders were more likely to show up, with a no-show rate of 15.7% vs 9.7%.11 However,

texts were found to be valuable in serving as a convenient way for patients to cancel, since 73%

of cancellations came from texts.11 Creating an easy way for patients to cancel is helpful because

those cancelled appointments can potentially be filled which leads to less money lost and

decreased wait times for other patients. A second study conducted by a MRI imaging clinic

assigned specific days for patients to be reminded by text and the remainder of the days to have

patients reminded by a traditional phone call.12 The no-show rate for the texting group was 3.8%

vs 5.1% for the traditional phone call reminder group.12A systematic review of 26 studies found

that patients who received text notifications to remind them were 25% less likely to no-show;

however, voice notifications were still more effective than text messages.13 The research found

that multiple reminders were more effective in improving appointment attendance. Sending two

or more text notifications increased attendance by as much as 19% compared to a single

notification.13

Scheduling Given that numerous studies have found that lead time is a critical factor in

reducing no-show rates, every effort should be made to schedule appointments close to the

current date.1,3,8 Instead of scheduling an appointment for months in advance, patients should

make their appointment closer to the date needed.14 Other scheduling strategies are including
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room for same day (walk-in) appointments each day, expanding evening and weekend hours, and

double booking patients.14 A systematic review found that using walk-in scheduling was more

effective in decreasing no-show rates when the current no-show rate is greater than 15%.15

Double booking patients should be done only in the morning so that the dietitian can get back on

schedule later in the day when patients fail to show up and should be considered with caution, as

it has the potential to increase wait times and result in a chaotic day.14

Telemedicine Telemedicine is becoming an increasingly popular practice. By offering

initial and follow-up visits over the phone, an outpatient nutrition clinic was able to lower their

combined no-show and cancellation rate to between 16-17%.2 However, some insurance

companies will not cover telemedicine appointments, and dietitians should be aware of potential

legislation which may place restrictions on practicing across state lines.

No-Show Policy As part of developing strategies to decrease no-show rates, it is

important for dietitians to develop a no-show policy. As part of the policy, an outline of what

counts as a no-show and the procedures to follow after a no-show occurs may be included.

Scheduling and monetary concerns are also potential areas to be addressed. The no-show policy

may address when and how to follow-up with a no-show, whether they should be restricted to

only certain appointment hours, and after how many instances should the client be fired (i.e.

permanently removed from the schedule and no longer allowed to make any appointment in the

future). For example, a no-show policy may state that no-shows must be contacted within 24

hours of the missed appointment to determine why they missed the appointment and attempt to

reschedule. After three missed appointments, perhaps the client is restricted to only appointments
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at the end of the day, so clinic staff can leave early if they fail to show. The monetary aspect of

the no-show policy should include whether a missed appointment fee is charged and whether a

client would be required to pay the partial or full amount of the visit up front if they have missed

appointments. If a no-show fee is charged, the policy must include under which, if any,

circumstances the fee may be waived.

Financial

Pricing Both private practice dietitians and hospitals have used pricing strategies to try to

improve no-show rates. One strategy might involve offering packages so patients pay for

multiple visits upfront, sometimes offering a discount for follow-up visits.2 Another option

utilized is charging half of the cost of a package initially and charging the remainder midway

through the package.2 Dietitians have reported 80% of clients returning for three pre-paid

sessions compared to 30% who did not purchase a package upfront, and a medical center found

70% of clients had returned through session five out of seven follow-ups when they had pre-

paid.2

Fees As part of their policies, some dietitians keep a credit card on file and charge

patients even if they do not show up.2 Some patients may willingly pay this fee, while others

may react angrily.14 Before adding a missed appointment fee, it is important for dietitians to

evaluate their strategies to make sure they are doing everything possible to prevent no-shows.14

Health Motivators Patients may respond positively to incentives, such as the use of

laboratory values or dietary analysis as proof of improvement in their health.2 Showing patients
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visible proof that their efforts are paying off through lowered blood pressure, improved lipid

panels and hemoglobin A1c levels, or improved body composition, can be motivating.2 This is

likely to be especially true if the patient's goals were related to improving these measures. In

addition, other dietitians offer their clients a discount for referrals or during National Nutrition

Month as an incentive; however, this success of this strategy is unknown.2

Dietitian Specific Skills

Patient Education Striking a careful balance between giving patients too much

information or too little information is key to decreasing no-show rates. By letting clients know

ahead of time what their next appointment will cover and taking steps to ensure only a small

amount of information is doled out per session, dietitians may be able to encourage patients to

come back for their next appointment.2 In particular, saving topics that clients frequently want to

learn more about for future appointments may help reduce no-show rates.2 A private practice

dietitian successfully used this strategy to increase completion rates of 3 counseling sessions for

diabetes from 60% to 95%.2 Some dietitians also include a handout or brochure with success

rates of patients who have come back for multiple follow-up appointments.2 By creating a

handout with information on the topics to be covered over the course of twelve weeks, a dietitian

was able to double the number of clients returning.2 Another dietitian increased her follow up

rates from 75% to 99.5% by sending her potential clients a package of information about the

services she offered.2 However, if a dietitian provides too little new information to a patient on

the first visit, they may not understand why further appointments are needed and thus miss their

future appointments.10
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Behavioral Contracting A behavioral contract is a document signed and dated by the

client that lists their goals. It may also include sections where the client details why they want to

work on their chosen goals, any anticipated difficulties, steps to meet their goals, and rewards or

consequences. A tertiary medical center felt that behavioral contracting was an important factor

in their client retention, citing improved accountability and commitment.2 Their pilot test

reported 85% of clients continuing to show up to appointments at week 6.2

Individualization Working with the patients to create a plan specific to their needs may

improve motivation and no-show rates. Discussing the client’s goals, needs, concerns, and ideas

are all important aspects of a session.2 The plan may also include the costs of sessions and when

and how long follow-up appointments will be made for based on the individual patient’s needs.2

This process can improve the patients understanding and motivation. If the patient decides they

are not ready to invest the time, money, and energy into following the plan to reach their goals,

then a follow-up appointment does not need to be made.2 A dietitian in private practice used this

approach successfully and had over 90% of patients complete their entire plan.2

Counseling Skills Along with individualizing appointments, mastering counseling skills

may be beneficial in decreasing no-show rates. While handouts are useful, dietitians must avoid

overwhelming their patients with too much information.2 Recognizing the difficulties patients

face in making changes and giving them ample time to share their progress is an important part

of the session. Motivational interviewing can increase motivation to attend appointments and

encourage behavior change.16 Focusing on improvements the patient has made and providing
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them with assignments to complete before the next session are two other effective counseling

skills.

Communication Developing rapport and maintaining a positive attitude towards the

patient increases the likelihood they will return for another appointment.2 It is also key for

dietitians to remember to pay attention to their body language, because non-verbal

communication is also important. When encouraging a patient to schedule an appointment, using

deliberate word choice may nudge the patient into making the appointment.2 For example, asking

the patient when they would like to have their next appointment is preferable to asking them if

they would like to make another appointment.2 Encouraging the patient to make an appointment

before they leave or calling the next day to make the appointment may be of benefit, however

there is the potential that the patient may schedule the appointment and then no-show.2 Lastly,

communicating with the patient’s other health care team members to ensure a team approach was

requested by patients of dietitians in one study.10

Nutrition Counseling Center at Northridge

Background NCC is affiliated with UVAHS and has three part time registered dietitians

making up a total of 2 full time equivalents (FTE). Dietitians at NCC counsel adult patients for a

wide variety of nutrition concerns such as diabetes, kidney disease, and weight loss, with the

exception of eating disorders.

Scheduling Process Patients either contact NCC to set up an appointment or are referred

by their physician, in which case administrative staff will contact the patient to set up an
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appointment within 72 hours of receiving the referral. Typically patients can be seen within the

next week and if patients are seen later than one week out, it is usually per their request.

Reminders Patients receive both mailed letters and an automated phone call three days

before their appointment via Telebox to remind them of their appointments as part of standard

UVAHS procedures. They can also choose to cancel their appointment through Telebox,

although this will not remove them from the dietitian’s schedule.

Current Strategies NCC has tried to improve their no-show rate by calling people who do

not confirm their initial appointment with Telebox, although it is unclear if this has helped. NCC

does not charge for missed appointments; however, after missing 3 appointments patients are

“fired”.

No-show Rates at NCC

Data NCC started collecting data via EPIC reports on their no-show rate in May 2018. During

the 2018 year, NCC had a combined average no-show and cancellation rate of 40.6%. An

average of 42% of initial appointments are cancelled or are no-shows, which is only slightly

higher in comparison to the combined cancellation and no-show rate for follow up appointments

of 39%. This is similar to the combined no-show and cancellation rate of 49.7% of 3 other

outpatient nutrition counseling centers based on an email survey and to the ambulatory national

average no show rate which is 23-42%.1,7 The highest initial no-show and cancellation rate was

in December 2018, which was 54%. The lowest was in July 2018, which was 28%. For follow up

visits, the highest no-show and cancellation rate was in May 2018 (51%) and the lowest was in
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July 2018 (28%). Based on data from May 2018 to December 2018, patients are most likely to

no-show for their appointments on Thursday (43%) and least likely to no-show on Friday (35%).

NCC Combined No-Show and Cancellation Rate Average by Day of Week

Monday Tuesday Wednesday Thursday Friday

40% 37% 42% 43% 35%

NCC Initial Appointment Combined No-Show and Cancellation Rate by Month

May 2018 52%

June 2018 38%

July 2018 28%

August 2018 44%

September 2018 47%

October 2018 30%

November 2018 43%

December 2018 54%

January 2019 44%

February 2019 35%

March 2019 35%

NCC Follow-Up Appointment Combined No-Show and Cancellation Rate by Month

May 2018 51%

June 2018 36%

July 2018 28%

August 2018 30%

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September 2018 43%

October 2018 50%

November 2018 38%

December 2018 37%

January 2019 51%

February 2019 36%

March 2019 36%

Appointments An average of 55.5% of clients at NCC have Aetna insurance since all UVAHS

employees have an Aetna insurance plan. Through a partnership between UVAHS and Aetna, all

employees are eligible to receive one free hour long nutrition counseling session per year. For

patients who do not have health insurance or whose insurance will not cover their nutrition

counseling session, there is a sliding pay scale determined by the UVA finance department and

the length of the appointment time. All sessions range from 15 minutes - 1 hour, with self-pay

follow-up sessions typically being shorter in length. A self-pay 15 minute initial visit costs from

$6 - $46 and a full hour visit costs from $6 - $184. Follow-up appointments are slightly cheaper;

a 15 minute visit costs $6 - $40 and an hour long appointment costs $6 - $160 for self-pay

patients. Almost all patients are seen in person, with the exception of a few initial phone calls.

Factors Affecting NCC In some aspects, NCC aligns with some of the data found in the studies

reviewed. NCC has it highest no-show rates on Tuesday and has more patients no-show for an

initial appointment compared to a follow-up appointment. However, based on an interview with

Austin Shelley, RD, CNSC, the director of NCC, the average wait time for an appointment is

typically no more than one to two weeks. This is interesting given how lead time was found to
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heavily influence the no-show rate in other studies, however it appears that other factors must be

driving the no-show rates at NCC.

PURPOSE

The purpose of this review is to evaluate causes of no-show rates at the University of

Virginia Nutrition Counseling Center at Northridge in Charlottesville, Virginia. Using this

information, this project will utilize best practices to reduce missed appointments and develop an

action plan for NCC.

PROJECT METHODS

The project will begin with a review of the current evidence on no-show rates and data

from NCC. Afterwards, a survey will be created and shared with staff at NCC prior to holding a

meeting to determine which practices should be implemented on a trial basis to reduce no-show

rates. Once the strategies have been implemented, data will be kept to measure the effect on no-

show rates and to determine what changes may need to be made to the tools or to NCC to

improve the no-show rate.

RESULTS

After deliberation, the NCC team decided on a multi-pronged strategy to begin tackling

the no-show rates. First, an agenda map was created. The agenda map consists of several empty

circles with suggested topics below, such as “portion control”. The patient can choose from the

ideas listed on the sheet or come up with their own and write them in the circles. The agenda

maps were created with the goal of encouraging patients to come back to their next appointments
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since they would have a clear idea of what would be covered next and what areas they wanted to

improve on.

Second, a no-show policy was produced since there was previously not one on file at

NCC. The no-show policy states that patients who miss their appointments three times will no

longer be able to schedule appointments. This has been added to EPIC so it can be easily sent to

patients. The NCC dietitians have come to an agreement to use this policy with the aim of

terminating any patients who habitually miss their appointments.

Third, a patient feedback card was developed to gather more insight into areas NCC can

improve upon to further lower the no-show rate. The patient feedback card questions what went

well, what could be improved, and asks patients to rank their overall visit using a scale. The

cards are prominently displayed on the front desk and a box was provided so patients could

remain anonymous if they desired. The NCC team will meet to review any patient feedback

cards collected on a quarterly basis. So far, few patients have filled out feedback cards, which

may mean that an incentive needs to be offered to collect this data.

Finally, a brochure was constructed to market the services NCC offers to other providers

and potential patients. As part of this strategy, patients from NCC were contacted by their

dietitian to ask for success stories that could be included in the brochure. The brochure includes

information on what conditions NCC treats, programs offered, quotes from clients, and details on

insurance, MyChart, and how to make an appointment.

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DISCUSSION

In 2019, the combined average no-show and cancellation rate is 41.5%, which is similar

to the data collected in 2018. Interestingly, so far more no-shows have been from follow-up

appointments, which differs from the previous year. The no-show rate jumped back up to 51%for

follow-ups in January, which is the highest it has been since May 2018 when it was also 51%.

The new combined no-show and cancellation rate using data from May 2018 to February 2019 is

40.8%. It will take several months before there will likely be any significant changes in the no-

show rate since implementing several strategies beginning in February 2019. Increasingly,

cancellations are becoming a problem at NCC. This may point to a need to develop a separate

cancellation policy and consensus on the difference between a cancellation and a no-show. If

patients cancel appointments and their slots are unable to be filled by another patient, this still

leads to negative impacts on NCC for both other patients and on the clinics bottom line.

Reducing the no-show rate is complicated by a myriad of factors that make it hard to

pinpoint the most effective changes. Addressing the problem from multiple angles may increase

the chances for improvement. Likely the next steps involve a stronger focus on cancellations

specifically and on increasing referrals. This includes tracking the number of referrals received

from other providers to help guide marketing as well as educating providers. In addition, there

are also plans to develop a group of dietitians who can work together to improve no-shows and

share data and strategies. Contact information for outpatient and private practice dietitians in

Maryland was collected during the Maryland Academy of Nutrition and Dietetics annual meeting

to facilitate this process.

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A major limitation of this project is that the results may not be able to be applied to other

nutrition clinics. Further, it is difficult to track the success of each strategy that was implemented

and is impossible to fully understand their potential impact. Finally, the data collected for this

project is somewhat inaccurate. For example, 15% of visits that are coded as a cancellation or

no-show are rescheduled. Of those 15%, it is unclear how many no-show to their rescheduled

appointment. This data makes a difference because if a patient cancels a week ahead of time,

there is a higher chance that their original appointment can be filled by another patient. Until a

better process is able to be used, the true no-show rate will not be discovered.

This project was an excellent opportunity to learn more about the various aspects that can

impact no-shows and the challenges that arise from trying to decrease the no-show rate. The

importance of working as a team to determine the most effective strategies and best direction to

proceed cannot be understated. Collaboration meant that all angles could be thoroughly assessed

by many different viewpoints. The project also provided practice in marketing material and

patient education development, as well as key insight into important administrative tasks.

Finally, presenting at the Maryland Academy of Nutrition and Dietetics and Virginia Academy

of Nutrition and Dietetics were great chances to network and improve presentation skills.

SUMMARY & CONCLUSION

No-show rates are inherently driven by numerous complex factors. Demographics appear

to play a role. Clinic specifics, such as lead time, can also impact no-show rates, however unlike

many other medical practices, appointments with dietitians in an outpatient or private practice

may be available sooner. Other considerations such as insurance coverage, the patient’s
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emotions, and their specific medical conditions play a role. It appears that some patients do not

see their visit to the dietitian as being important or fail to understand the benefits of seeing a

dietitian if they do not notice any obvious signs of improvement in measures such as their

weight. More simplistic explanations for no-shows cannot be discounted, such as a patient

simply forgetting about their appointment. Although they cannot be entirely eliminated,

dietitians have multiple potential avenues to improve no-show rates. These include various

pricing strategies, improvement in counseling skills, tailoring sessions to patients, use of

incentives or fees, marketing, and improved communication amongst other healthcare team

members. In the future, more research needs to be performed on dietitians’ no-show rates to

develop best practices.

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Appendix A: Agenda Map

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Appendix B: No-Show Policy

Dear,

We are sorry we missed you at your appointment with us on ______ at the Nutrition Counseling Center
at Northridge. You are receiving this letter because you have missed two appointments with our clinic.

We do not practice overbooking, so no-shows and cancellations with less than 24 hours’ notice limit
access to appointments for our other patients.

As such, please be advised of our cancellation and no-show policy: patients who have missed 3 or more
appointments without a minimum of 24 hours’ notice will not be allowed to reschedule another
appointment. Please contact us if you have any further questions.

Thank you!
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Appendix C: Patient Feedback Card

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Appendix D: Marketing Brochure

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