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Reducing the prevalence of missed primary care appointments in community health centers
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Reducing the prevalence of missed primary care appointments in community health centers
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Running Head: REDUCING MISSED PRIMARY CARE APPOINTMENTS 1
Reducing the Prevalence of Missed Primary Care Appointments in Community Health Centers.
Capstone Project Paper
Adijat O. Ogunyemi
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
May 2020
REDUCING MISSED PRIMARY CARE APPOINTMENTS 2
Executive Summary
The vast dissimilarities in health care, along with the persistent pattern of shorter lives
and poorer health in the country, led to the social work grand challenge focused on closing the
health gap (Institute of Medicine, 2013). Differences in healthcare access adversely affect low-
income individuals and communities. The societal goal of the close the health gap grand
challenge is to achieve health equity and create a socially-oriented model of healthcare that
produces large-scale social innovations (American Academy of Social Work and Social Welfare,
2018). Abolishing the cause of health disparities in the country and promoting ground-breaking
interventions that will eliminate the gaps that exist for marginalized populations is also part of
the goals of the challenge. The grand challenge also seeks to improve primary and preventive
care (American Academy of Social Work and Social Welfare, 2016).
Primary and preventive care could save one hundred thousand lives each year and reduce
healthcare spending. According to the Centers for Disease Control and Prevention, if people
received primary care and followed through with treatment recommendations, they will live
longer and healthier lives (Beaton, 2017). Unfortunately, in community health settings, the issue
of missed scheduled primary care appointments is an intractable problem many Community
Health Centers (CHC) in low-income communities face regularly. This is because missed
primary care appointments cost the United States $150 billion each year in health expenditures
(Gier, 2017). The problem of missed scheduled primary and preventive care appointments in
CHCs is one of many stubborn problems within the grand challenge that contributes to adverse
health outcomes.
The Health Resource and Service Administration (2018) defined CHCs as a community-
based organization that provides medical, oral health, mental health, vision care, substance abuse
REDUCING MISSED PRIMARY CARE APPOINTMENTS 3
disorder, and other patient support services to patients in medically underserved communities.
CHCs were created in the 1960s when President Lyndon Johnson declared War on Poverty in
1964 as part of his great society movement (Lawson & Lawson, 2008, p. xxii). The first two
CHCs in the United States opened within a year of the declaration in Mound Bayou, Mississippi,
and Dorchester, Massachusetts. These innovative CHCs propelled a national movement that has
positively impacted the health care system until the present day.
CHCs remain a large system within the health system and provide high-quality one-stop-
shop comprehensive primary and preventive care services to millions of people. CHCs operate
under the governing of the Health Resource and Service Administration (HRSA). HRSA is the
central federal agency of the U.S. Department of Health and Human Services, whose mission is
to advance and progress health care access to people who are medically disadvantaged,
economically vulnerable, and or geographically isolated (Health Resource and Service
Administration, 2018). CHCs receive funds from HRSA in the form of government grants to
provide primary and preventive care services in underserved communities.
The Reach-Out Program is the innovation aimed to decrease the prevalence of the social
problem through patient activation and engagement strategies. The Reach-Out Program uses
Community Health Workers to form personalized alliances with patients in a way that appeals to
their unique motivation about healthcare and strengthen their relationship with their medical
home. The purpose of the project is to improve patient engagement in primary care services,
improve health outcomes, decrease the incidence and prevalence of missed primary care
appointments in CHCs, and decrease health expenditures. Ultimately, the innovation will be able
to close the gaps in healthcare by elevating the patient’s experience and interaction with primary
care services.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 4
The issue of missed appointments in CHCs has become an enormous part of American
health expenditures. The lack of emphasis on primary and preventive care has led to policy and
practice changes. The healthcare industry is moving away from fee-for-service care and towards
value-based care. Historically, healthcare providers and organizations were reimbursed under a
fee-for-service model. Fee-for-service meant that they were compensated for each test, treatment,
procedure, etc. they perform regardless of whether such intervention resulted in better health
outcomes for the patient. With the fee-for-service model, healthcare providers and organizations
were compensated for quantity over quality (Lambert, 2018).
Value-based healthcare is a type of health care delivery model that only pays healthcare
providers based on the quality of care they provide to patients. The agreements of value-based
care reward the healthcare provider for using evidence-based approaches to help patients live
healthier lives. It also pays providers for assisting patients in reducing the effects and incidence
of chronic disease. Also, the value-based care model requires a team-oriented patient care
approach that prioritizes patient engagement with their respective medical homes (i.e.,
Community Health Centers). The social problem is significant to current policy and practices, as
evidenced by the increasing demand for the improvement of patient engagement (Heath, 2017).
The project implementation aims to promote patient activation and engagement in
primary care. A patient who is engaged in primary care services is more likely to make a
balanced and informed decision about their healthcare and is expected to live longer. The
capstone innovation will provide meaningful contributions to closing the gaps in healthcare by
improving the patient experience, decreasing the cost and prevalence of no-shows, and
improving health outcomes.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 5
The innovation will be piloted at one of the local CHCs in the Metro Detroit area in
Michigan. Within the first year of implementation, the most critical milestones The Reach-Out
Program will need to meet is the increase in patient engagement and satisfaction in primary care
services and reducing the cost of no-shows in CHC. The two milestones are important in the first
year of implementation because it will provide proof of concept and will allow for the program
to expand to other CHCs in Michigan and beyond.
Conceptual Framework
Social Problem within the Context of The Close the Health Gap Grand Challenge
Health disparities refer to a higher burden of illness, disability, injury, and mortality
experienced by a group of people relative to another. This occurs across many dimensions, such
as socioeconomic status, race, location, gender, sexual orientation, and disability status (Artiga,
Orgera & Pham, 2020). Many groups of people are at a disproportionate risk of experiencing
adverse health outcomes, lacking access to health care, or being uninsured. The inequalities lead
to substantial gaps in health. For example, low-income individuals and families, which constitute
people of color, are more likely to face healthcare access barriers, are uninsured, and are
vulnerable to higher rates of chronic health diseases. It is expected that by the year 2025, over
half of the United States population (52%) will be people of color. As the country’s population
becomes more diverse, it is increasingly important to address disparities in health not only to
decrease healthcare costs but also to improve the overall health gain of the country (Artiga et al.,
2020).
Low-income individuals and communities are not getting the health care they desperately
need due to frequently missed scheduled primary care appointments in CHCs. Missed
appointments are also known as no-shows. Research reveals that regularly, up to 55 percent of
REDUCING MISSED PRIMARY CARE APPOINTMENTS 6
patients do not show up for their scheduled primary care appointments across the country (Ullah
et al. 2018). A no-show could mean the difference between early versus late detection of
diseases. When patients miss their primary care appointments, they run the risk of poorer health
or dying prematurely because they did not receive timely intervention. Missed appointments
represent a significant risk marker for all-cause mortality (McQueenie et al., 2019).
The target population for the social problem is the low-income population in medically
underserved communities. Community Health Center patients are primarily school-based health
center patients (children), veterans, agricultural workers, public housing patients, and homeless
patients. These patients are predominately members of racial/ethnic minority groups and low
socioeconomic status (National Association of Community Health Centers, 2018). Patients that
miss their appointments are more likely to be younger (between the ages of 18 – 40), black or
Hispanic, and have Medicaid insurance coverage (Kaplan-Lewis & Percac-Lima, 2013). As
stated by the World Health Organization (2019), poverty and chronic diseases interrelate in a
vicious cycle. This patient population is also more at risk of dying prematurely (Cheng &
Kindig, 2012). Missed primary care appointments disrupt the continuity of the delivery of
healthcare services and lead to dissatisfaction in the patient experience due to more extended
wait periods for new appointments (Ullah et al., 2018).
Cause of Problem, Relevant Concepts, Existing Research & Environmental Context
Existing research uncovers the cause of the problem, relevant concepts related to the
social problem, and prior ineffective strategies that have been implemented. The cause of this
social problem is the social determinants of health (SDOH). The Office of Disease Prevention
and Health Promotion (2018) defines SDOH as the environmental settings that people are born,
live, play, work, work, worship, and age that impacts an extensive range of health, level of
REDUCING MISSED PRIMARY CARE APPOINTMENTS 7
functioning, risk, and quality-of-life outcomes. SDOH factors include economic stability,
neighborhood and physical environment; education; food; community and social context, and
health care systems (Artiga & Hinton, 2018).
The SDOH factors that impact individuals and communities are often based on years of
social isolation and discrimination. Ullah et al. (2018) identified three kinds of SDOH barriers
that lead to missed appointments. These barriers are personal, structural/organizational, and
financial obstacles. Personal barriers include living in a low-income community (Anderson et al.,
1997), lack of education, and individual attitudes towards healthcare (Ullah et al., 2018). A
patient who is likely to miss an appointment is one who is from a low-socioeconomic group, has
a large and unstable family unit, has a history of no-shows, and has no ongoing relationship with
a physician (Barron, 1980). Structural or organizational barriers include lack of transportation,
lack of awareness of available resources, not knowing the reason for an appointment, challenges
with appointment systems, and the interaction between healthcare providers and their patients.
Financial barriers include low socioeconomic status and inability to afford co-pays (Ullah et al.,
2018). Not every inhabitant of the United States has the same opportunities to be healthy. Studies
have shown that life expectancy in the United States varies geographically and, in some cases,
dramatically. The differences in socioeconomic status can explain the disparities in life
expectancy, race, ethnic, behavioral risk factors, and health care factors (Dwyer-Lindgren et al.,
2017).
The enactment of the Affordable Care Act (ACA) is another relevant concept in the
social problem. In 2010, the ACA provided a significant narrowing of longstanding disparities
that exist among low-income and medically/geographically disadvantaged communities. About
20 million Americans became newly insured as a result of the ACA, which significantly
REDUCING MISSED PRIMARY CARE APPOINTMENTS 8
decreased uninsured rates to an all-time low (The Statistics Portal, 2018). The existing research
about the social problem also uncovers multiple strategies that have been previously used in an
attempt to eliminate the problem. These strategies include automated phone calls and text
messages, emails, live phone calls, discharge of chronic no-showers, transportation services, and
no-show fines are all strategies that have been implemented to eliminate the problem in other
outpatient private settings. These strategies alone are not sufficient for CHC because of the social
determinant of health barriers that many CHC patient populations regularly face (Mehra et al.,
2018)
Social Significance of The Problem
Avoiding medical care can result in the late detection of disease, decreased survival, and
preventable human suffering (Taber et al., 2015). The problem of missed primary care
appointments is socially significant because of the real impact it has on society. It impacts people
in a way that can be detrimental to their health throughout the life span. No-shows negatively
affect patients and results in longer wait times, lack of continuing in care, lower quality of care,
poor health outcomes, and lower patient satisfaction (Mehra et al., 2018).
As stated earlier, the CDC reported that one hundred thousand lives could be saved each
year if people took primary and preventive care seriously (Beaton, 2017). Patients who miss their
primary health care appointment run the risk of poorer health and shorter lives, which contributes
to the decline in life expectancy in the country. Nationally and internationally, America is faced
with a challenge in the area of life expectancy. When compared with other countries, such as
Canada, the United Kingdom, and Mexico, there is a significant disparity in life expectancy
between the inhabitants of those countries and Americans (World Bank, 2017).
REDUCING MISSED PRIMARY CARE APPOINTMENTS 9
These health gaps disproportionately impact medically and geographically disadvantage
communities. Still, it should not be viewed as a “poor people problem” because it diminishes the
overall health gain for the general population. Similarly, missed appointments negatively impact
other actors, such as insurance companies/payer sources, CHCs, and healthcare providers. The
problem has significant financial consequences on health centers and is an intractable headache
for healthcare providers (Abram, 2018). Clinics experience loss of revenue that negatively
impacts the ability to improve patient access and care (Triemstra & Lowery, 2018), and
healthcare providers experience inefficient use of their time due to unused appointment time
slots.
Logic Model, Theory of Change
The patient-centered approach of The Reach-Out Program is supported by the systems
theory, which is premised on the idea that an effective system is built on individual needs,
attributes, expectations, and rewards of the people living in the system (Bertalanffy, 1967). A
system is successful when it considers the individual needs, attributes, expectations, and rewards
of the people living in the system. The Reach-Out Program uses the system theory to engage
patients in primary care by forming personalized alliances with the patient in a way that caters to
their unique motivations about healthcare, focuses on the patient's interactions with their CHC,
and ensure that those interactions are understood and defined (Rhodes, 2012).
Evidence that supports the innovative capstone practice is the increasing demand for
value-based care (Heath, 2017). Value-based care rewards providers for providing evidence-
based approaches to help patients live healthier lives and assisting patients in reducing the effect
of chronic healthcare disease. To improve how healthcare is delivered in the United States, The
Department of Health and Human Services (HHS) is focusing its energies on using incentives to
REDUCING MISSED PRIMARY CARE APPOINTMENTS 10
motivate higher-value care by gradually tying payments to patient health outcomes (Burwell,
2015).
The logic model, which can be found in Appendix A. draws a clear framework of how
the innovation aligns with the theory of change. A System can constitute individuals, families,
communities, and organizations. In other for a system to work effectively, the many elements of
the system must work together to make it a functional whole (Rhodes, 2012). For example, a
social worker working with a client should consider the bi-psycho-social aspects of the client by
exploring the physical and psychological functioning, community and social structures, social
relationships that impact the client (Rhodes, 2012). The same is for the innovation. It seeks to
assist patients with exploring and eliminating their individual SDOH barriers that lead to missed
appointments. The logic model provides an illustration that explains how The Reach-Out
Program will help patients (individuals and families) interrelate with their CHC (organization). It
gives a visual statement of the necessary resources and activities that will bring about the output
and outcomes, which will create the desired impact for low-income communities. The logic
model depicts the specific inputs and outputs that are needed in other for the innovation.
Capacity building initiatives such as investment of staff time and training and the buy-in of
major stakeholders are the most critical inputs for the innovation.
The participants are the patients, CHCs, and local low-income communities. The
activities of the program are built on the five essential functions of the Community Health
Worker in other for the desired impact of the decrease in missed appointments and improvements
in heal outcomes to occur. The logic model also provides an itemized view of the processes
needed in other for the innovation to become a reality and work effectively. The innovation will
need staff salary, training and development, CHC orientation, and money to fund the equipment
REDUCING MISSED PRIMARY CARE APPOINTMENTS 11
required for day-to-day job duties. The key personnel of The Reach-Out Program is the
Community Health Worker, who has completed the Community Health Worker Training at an
approved training program in Michigan and desires to work in the medically underserved
population.
The training and development process for innovative capstone practice will be completed
upon the procurement of the personnel. The personnel will undergo a two-day Community
Health Worker training in patient activation and engagement. The CHC staff will also receive
on-site training on how the Community Health Worker would fit into the clinic operations.
Lastly, the money will be needed to purchase equipment and fund the entire program. The
overall vision of the innovation is to improved health outcomes and decrease the prevalence of
missed appointments.
Problems of Practice and Innovation
Innovation
The Reach-Out Program is the innovation created to improve patient activation and
engagement in CHC by using Community Health Worker (CHW) to form personalized alliances
with patients. The CHW role will appeal to patients in a way that focuses and supports their
unique motivation about healthcare and strengthens their relationship with their medical home.
The Reach-Out Program has been explicitly designed for Community Health Centers. The
purpose of the project is to improve patient engagement in primary care services, improve health
outcomes, decrease the incidence and prevalence of missed primary care appointments, and
decrease health expenditures in Community Health Centers. The CHW's role in the innovative
capstone practice may also be referred to as Patient Specialist or Patient Activation and
Engagement Specialist.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 12
The innovation comprises five essential components; outreach, counsel, connect, educate,
and empower. The CHW will reach out to patients to build a foundation for ongoing
relationships and to activate the participation of new patients in primary care. They will counsel
patients about the importance of primary care, connect patients to primary and preventive care
services by assisting with appointment scheduling and rescheduling and educate patients about
the importance of keeping appointments and implications on health outcomes. They will
empower patients by connecting them to the Social Determinants of Health resources. The CHW
will also serve as a liaison between patients and their local community health centers in a way
that fosters learning versus blaming culture.
Contributions the innovation will make to improve Gaps in Health Care.
The Community Health Worker of The Reach-Out Program will improve the healthcare gaps by
doing the following.
1. Improve patient experience and engagement in primary care services.
2. Improve recognition of the social determinant of health needs that lead to missed
appointments.
3. Improve patient access to primary and preventive care services through rapid access to
their primary care provider, i.e., Scheduling appointments no later than a week from the
day of contact.
4. Improve collaborative management of patients with psychosocial issues through
assistance with accessing social determinant of health resources.
5. Improve communication and collaboration between patients and their primary care
providers.
6. Provide concise and timely feedback to primary care providers as needed.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 13
7. Increase job satisfaction among primary care providers.
8. Increase patient satisfaction with primary care services.
The Reach-Out Program draws on existing research, interviews with first-order actors,
and professional experience to explain how it will improve the no-show problem. Patient liaisons
have long been used in various health systems. For many years, ombudsman, patient advocates,
or guest relations representatives have been used in hospitals for the sole purpose of ensuring
that the patient hospital experience is a positive one (Greenwich Hospital, 2019). This is a
proven effective approach to patient engagement and is lacking in CHC systems. While the
concept is not brand new, the innovation is, however, disruptive because it has not been done in
CHCs before, and it will positively impact changes in the CHC system. Patients will experience
what it truly means to have and be a part of a medical home.
Establishing a foundation for an ongoing relationship with a patient is an indisputable
way to get them to show up for appointments (Solution Reach, 2020). A review of the status of
the current environment shows that the capstone project is the answer to the missed primary care
appointment problem. In addition to establishing a foundation of an ongoing relationship,
research also suggests that increasing the organization's awareness of the no-show problem,
patient education, and provision of patient-centered care will decrease no-shows (Mehra et al.,
2018).
The innovation is backed by research explained by the theory of change. The innovation
argument for the project is that it is sustaining. Research reveals a strong correlation between
missed primary care appointments and health outcomes. This is because primary care
professionals are frontline essential health workers, who are often the first to see the early signs
of illnesses. An adult who is engaged in primary care services has 19% lower odds of premature
REDUCING MISSED PRIMARY CARE APPOINTMENTS 14
death (Primary Care Progress, 2018). This means that there will be an increase in life expectancy
when people are engaged in primary care. Insurance companies will experience a reduction in
the cost of care because chronic illnesses will be appropriately managed. The likelihood of a
positive health outcome is possible with primary and preventive care. The improvements and
results of the innovation will create a return on investment for the payer sources.
Stakeholder Perspectives
CHCs, health care providers, Michigan Primary Care Association (MPCA), and
insurance companies/payer sources are essential stakeholders tied to the social problem and
innovation. CHCs is a vital stakeholder because it is the primary system where the problem
exists and where the change will be housed. The issue of missed appointments represents a
significant financial loss for healthcare systems such as CHC (Perron et al., 2010). CHCs are
safety-net clinics that provide primary and preventive care services to underserved communities.
High rates of missed primary care appointments have been identified as one of the most
significant barriers to health care access in the CHC system. Research uncovers that CHCs, clinic
staff, and healthcare providers identified high missed appointment rates as a significant problem.
CHCs have reported that missed appointment results in unused appointment slots, underutilizing
of healthcare provider's time and also impacts waits and delays for other patients. (Mohammadi,
et al., 2018).
Healthcare providers are individuals who possess degrees and training in healthcare fields
such as a doctor of medicine (MD), osteopathy (DO), podiatrist, dentistry, chiropractic medicine,
psychology, optometry, nurse practitioner, nurse-midwifery, or clinical social work (Berkeley
Human Resources, 2020), These providers are professionals who have been authorized to
practice within their scope as defined by law in their respective States. Healthcare providers are
REDUCING MISSED PRIMARY CARE APPOINTMENTS 15
the frontline workers in CHCs. They provide direct primary and preventive care services to
patients and are connected to the problem because they play a role in the patient experience and
influence health outcomes. When patient’s no-show for their scheduled appointment, it interrupts
the healthcare providers' efforts to provide continuity of care (Nuti et al., 2012).
While there is no published public discourse from MPCA about the problem, MPCA is
an essential stakeholder because they are a community advocacy agency that influences and
advance health policy in the state's capital – Lansing and Washington D.C. MPCA offers
operational training and support to 45 CHCs Michigan. These CHCs provide primary and
preventive care to more than 700,000 patients in low-income communities in Michigan.
(Michigan Primary Care Association, 2020). MPCA also has grant funding opportunities for
programs that help lessen the disproportionate burden of chronic diseases in low-income
communities. Insurance companies are also essential stakeholders connected to the problem.
Insurance companies are the payer source for most healthcare services. Billions of dollars
go to waste each year as a result of the wicked problem. When patients do not show up, it leads
to the misspending of medical and administrative resources (Perron et al. 2010). The issue
impacts payer sources because they provide financial coverage for health expenditures. Missed
appointments accumulate into a considerable cost for them. Patients that are diagnosed with an
illness in its late stages require medical interventions that are more costly than preventative
care.
The positioning of Innovation within Broader Landscape of History, Policy, Practice, Local
Contextual Environment, Public Knowledge and Discourse
The inspiration behind the Reach-Out Program is in its mission to improve health care
access for low-income communities and influence positive change in their healthcare behavior.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 16
The innovation was formed through careful examination of the existing systems which
uncovered the missing links in the system. In the innovation argument, the innovation is
sustaining because it builds on CHW programs and research of patient advocates in the various
healthcare system.
The CHW program was adopted from China, where it all began as China's "Barefoot
Doctor" campaign. The Barefoot Doctors were laypeople with healthcare training that provided
primary health education and care to people in rural China in the 1950s–1970s (Lehmann &
Sanders, 2007). The CHW role has evolved over the years, and now CHWs perform a variety of
roles in many countries (Mukherjee, 2017). CHWs have been an integral part of CHCs and other
patient-centered medical homes in the United States. They have been instrumental in helping
with closing the gaps in health that by providing primary health care education to individuals and
families in CHCs. The Reach-Out Program builds on the CHW program by specifically targeting
the problem of missed scheduled appointments amongst low-income people in CHCs. Recent
public discourse about the social problem has been centered around the issue of the amount of
money the problem cost the United States in health expenditures. The no-show issue is costing
billions of dollars annually (Gier, 2017).
The dwindling life expectancy of Americans over the last two years has also been the
topic of current public discourse. In 2018, the Centers for Disease Control and Prevention (CDC)
made a public statement about this decline. Dr. Robert Redfield, CDC's director, called it a
disconcerting trend. Dr. Redfield further stated that life expectancy provides a snapshot of the
state of the country’s overall health and that the sobering statistic should serve as a call to action
because many of the disease killing Americans are preventable (Centers for Disease Control and
Prevention, 2018).
REDUCING MISSED PRIMARY CARE APPOINTMENTS 17
Justification of How the Innovation Considers Existing Opportunities for Innovation
The current opportunities for the innovation lie in the ineffectiveness of the current
products that are being used to address the problem for the target patient population. Calling a
patient for an appointment reminder without explaining the reason for the call and educating the
patient on the importance of keeping an appointment is not a sufficient intervention (Mehra et
al.,2018). The Reach-Out Program focuses on building longstanding powerful alliances with the
patient while considering the importance of patient education, institutional awareness, and
assistance with overcoming barriers related to the social determinant of health issues.
The Reach-Out Program utilizes CHW who are trained in Patient Activation and
Engagement strategies to create an environment in CHC where patients feel a part of their
medical home and are actively engaged in their journey to better health. There are also existing
opportunities for funding of the innovation with the significant stakeholders attached to the
problem. These stakeholders are HRSA and Insurance companies such as Blue Cross Blue Shield
of Michigan (BCBSM). HRSA was created in 1982 when the Health Resources Administration
and the Health Services Administration merged. HRSA aims to improve health care by
addressing the issues that lead to health inequities and disparities in the country through creating
and supporting innovative programs, skilled workforce, and increasing access to quality health
care services (Health Resources and Services Administration, 2018).
Grant funding opportunities are available through HRSA, which will support the initial
launch and implementation of the program. HRSA has legitimate power over CHCs, and its buy-
in will be an excellent win for the implementation and sustenance of the innovation. BCBSM has
grant opportunities that are aligned with the goals of The Reach-Out Program. One of BCBSM’s
potential funding sources, which matches the mission of the innovation, is the Michigan
REDUCING MISSED PRIMARY CARE APPOINTMENTS 18
Community Health Matching Program. This program offers grant funding opportunities to non-
profit community organizations to create, implement, and evaluate innovative approaches to
access health care issues. The Reach-Out Program will meet the criteria of eligibility for this
funding opportunity because it addresses healthcare access issues (Blue Cross Blue Shield of
Michigan, 2018). The funding from this program would help demonstrate the proof of concept. It
will also help pilot The Reach-Out Program at a local CHC to show the return on
investment.
Assessment of Innovation Overall Likelihood of Success
This innovation will provide meaningful contributions to closing the gaps in healthcare.
The innovation will be piloted at a local CHC in the Metro Detroit area in Michigan. Within the
first year of implementation, the most critical milestones the Reach-Out Program will need to
meet is the increase in patient engagement and satisfaction in primary care services and reducing
the cost of no-shows in CHC. The two milestones are important in the first year of
implementation because it will provide proof of concept and will allow for the program to
expand to other CHC in Michigan and beyond.
There is an increasing demand for healthcare professionals to improve patient
engagement (Heath, 2017). The patient engagement practice is, however, difficult to define and
measure, but it is an essential and necessary part of proving the contributions of The Reach-Out
Program. Patient activation and satisfaction have arisen as an essential gage of positive health
care experience. There is a variety of patient engagement measurement tools, and they offered in
the form of patient activation and satisfaction surveys and questionnaires. For example, CMS
employs the star rating system that provides a comprehensive understanding of patient
engagement at numerous healthcare systems (Centers for Medicare and Medicaid Services,
REDUCING MISSED PRIMARY CARE APPOINTMENTS 19
2017). The star rating also allows healthcare providers to review survey results that have been
completed by patients so the healthcare providers can make improvements in service delivery
(Heath, 2017).
Patient Activation Measure (PAM) is the assessment tool that will be used to assess
patient engagement after the intervention. There are a few versions of PAM, but the one that will
be used by the capstone project is the Short-Form PAM. It is a 13 Question Survey item. The
Short-Form PAM is more appropriate for the primary care setting. Insignia Health licenses PAM
and survey rights will be purchased from Insignia Health in other to use it at the community
health center. PAM is a necessary tool for measuring the success of the innovation because it
will be useful in promoting positive patient experience. PAM was created by a group of
researchers who were seeking to define patient activation after noticing gaps in the literature.
The researchers set out to develop an assessment for patient activation for health and wellness
behaviors (Heath, 2017). The Reach-Out Program will use patient activation and satisfaction
surveys to measure its goal of improving the patient experience.
The first year of implementation of the Reach-Out Program will include the ability to
show how innovation is decreasing the incidence and prevalence of missed primary care
appointments. This will be measured through data comparison. In the clinic where the Reach-Out
Program will be piloted, no-show data prior to its implementation will be compared with data 6
to 12 months after its implementation. The goal of improving health outcomes and life
expectancy is a long-term goal for the program, which will be reflected in the overall health
outcomes of the community where the innovation will be implemented.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 20
Project Structure, Methodology, and Action Components
Project Inquiry Format (Prototype) that Address the Identified Problem
The prototype for the capstone innovative practice is a training manual and resource
guide which can be found in Appendix B. The innovation is a service that will be delivered to
community health center patients. The purpose of the training manual is to have a standardized
plan of how all CHS will be trained for their role in The Reach Out Program. After the training,
the manual will also serve as a reference and resource guide for the CHW. The strategy behind
the prototype methodology is to have a set of guidelines and techniques that will guide the CHW
in doing their job the best way possible. The training manual contains various descriptive
information regarding the social problem, the large-scale system where the problem exists, an
overview of current programs as well as the innovation. Having this important information will
give the CHW a full picture of the importance of their role.
The prototype will be tested on a group of individuals that are familiar with the
community health system and social problem. The objective of the test is to determine the
effectiveness of the prototype. Will the prototype be sufficient in training and onboarding new
Patient Activation and Engagement Specialist? The answer to this question will be discovered
during the testing. At this time, the prototype has not been tested, but this is the plan. The
prototype is expected to impact the implementation of the innovation in a positive way because it
is the primary tool through which the Patient Specialist will be trained. It will help guide and
inform the work of the CHW.
Comparative Analysis of Market for the Innovation Relative to Alternative Options
The existing market has employed high-tech digital interventions that have been effective
in private outpatient clinics. These high-tech digital approaches are not appropriate for CHC
REDUCING MISSED PRIMARY CARE APPOINTMENTS 21
patient population due to the physical and financial barriers that they face. The National
Association of Community Health Centers (2019) reported 82 percent of CHC patients are either
uninsured or Medicaid recipients. Outpatient private clinics have more financial resources than
government-funded CHCs. Review of research uncovered phone calls and reminder text
messages as the most common tool being used to address the problem. Implementation of phone
calls and text messaging reminder system in CHCs cannot be optimally exercised due to limited
resources (Kaplan-Lewis & Percac-Lima, 2013).
Multiple research studies have emphasized the need for patient-centered intervention that
goes beyond reminder systems. For example, A research study completed by Kaplan-Lewis &
Percac-Lima (2013) found that the patients who no-showed for their scheduled appointments
were younger, black or Hispanic, and had Medicaid, self-insurance or unknown insurance.
Understanding who is more likely to no-show informs the work of the Community Health
Worker in The Reach-Out Program by enabling them to intervene before a no-show occurs.
Common reasons that patient misses their appointments are due to SDOH factors such as
communication, forgetfulness, not knowing the reason for a scheduled appointment, and
transportation issues.
Nuti et al. (2012) recommended a multifactorial approach intervention that includes
proactive planning, reminding, scheduling, and rescheduling of missed appointments. The
Reach-Out Program is a direct answer to the missing links in the existing market. Cooks et al.
(2015), reported in its research study that patients were most satisfied with medical care that was
personal to them.
Projects Methods for Project Implementation, Including Analysis of Obstacles, Alternative
Pathways and Leadership Strategies
REDUCING MISSED PRIMARY CARE APPOINTMENTS 22
The implementation strategy for The Reach-Out Program is to engage the stakeholders
and innovation partners from the beginning of the pilot. The assessment of the impact of missed
appointment identifies the issue as a significant problem that negatively impact the population’s
health. The plan is to pilot The Reach-Out Program in its first year (12 months) at a local CHC in
Detroit, MI. The reason for the ‘trial run year’ is to (1.) Help gauge the CHC the patients’
response to The Reach-Out Program, (2.) Confirm if the capstone innovation is ready for full-
scale implementation, (3.) Determine how to allocate time and resources best; and to assess
preparedness to measure the success of the program (The Department of Health and Human
Services, 2019). It is also important to mention that before the piloting, there some preoperative
activities that will take place. These activities are, non-profit applications, MOU with identified
CHC, personnel acquisition of Patient Specialist, and grant funding application/approval to cover
the expenses of the program. From professional experience, CHCs are accustomed to integrating
new programs in their system; therefore, assimilating The Reach-Out Program into the CHC is
not expected to pose any significant obstacles. The innovation will be led by the program creator,
who will be responsible for training the Patient Activation and Engagement Specialist and
training the healthcare providers at the CHC.
The long-term mission of the capstone innovation is to decrease the prevalence of missed
primary care appointments in CHCs and have The Reach-Out Program be integrated into the
CHC healthcare delivery system. During the pilot year, the most critical milestones the Reach-
Out Program will need to meet is the increase in patient activation and engagement in primary
care services and reducing no-shows in identified CHC. These milestones are important because
it will provide proof of concept and will allow the capstone intervention to fulfill its vision of
expanding to other CHCs in Michigan and beyond.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 23
The enactment of the Affordable Care Act (ACA) in 2010 provided a significant
narrowing of longstanding disparities that exist among low-income and medically/geographically
disadvantaged communities. About 20 million Americans became newly insured as a result of
the ACA, which significantly decreased uninsured rates to an all-time low (The Statistics Portal,
2018). The current political environment, along with the presidential administration’s has been
very vocal about its plan to repeal the ACA. This will negatively impact the Reach-Out Program
and complicate the implementation of innovative capstone practice.
The possible obstacle is currently not a factor in the implementation of The Reach-Out
Program because the ACA is still active. The pilot area has been researched and selected, and it
will be in Detroit, MI. Two CHCs have been identified as a possible pilot location. A meeting
has been scheduled with one of the CHC leadership to discuss the goodness of fit and
partnership. At this time, potential funding sources have also been identified, but no funds have
been obtained yet. The Reach-Out Program will operate under Havilah Human Services. Havilah
Human Services is a registered LLC in the State of Michigan with good standing. The company
is in the process of converting its entity type from an LLC to a Non-Profit Organization. Articles
of Organization for the switch have been completed but not yet filed. The resident agent of
Havilah Human Services is the program creator of the innovative capstone practice.
Projects Financial Plans and Implementation Strategy
Low-income communities have limited access to address the health-related need. The
assessment of the no-show trend identified how the issue affects the population’s health. The
Reach-Out Program will meet the need of the community in the area of patient engagement in
primary care because it fits with the shifting demand of the healthcare market towards value-
based care. The financial and sustainability plan of the innovative capstone project is financing,
REDUCING MISSED PRIMARY CARE APPOINTMENTS 24
credentialing, and evaluation. The identified funding models of the innovative capstone practice
are grant funding, Medicaid, and private companies such as Blue Cross Blue Shield of Michigan.
The credentialing will include the proper training of CHW. CHW will undergo a Michigan CHW
certification training and The Reach-Out Program training. The outcome of the pilot program
will also be published to support the effectiveness of the innovative capstone practice. The
evaluation plan will be addressed in the next section.
The Reach-Out Program needs three key personnel in other to fully function, and they are
program manager, CHW, and intern. The program manager will be a fully licensed master level
social worker with experience in working in a CHC setting in underserved communities. Next is
the CHW, who is the heart of the Reach-Out Program and will spend 100% of their time
reaching out, connecting, counseling, educating, and empowering the patients to engage in
primary care.
Lastly, the intern will be a bachelor’s level intern who desires to complete an internship
to fulfill the requirements of his or her degree. The intern will provide support to the CHW in
day to day work-related activities such as contacting patients to engage them in care. The student
will complete two semesters and will receive a total stipend of $2,500. The student will receive
$1250 at the end of each semester. Other planned operating costs include travel, laptops, staff
development, and telephone expenses. A travel allowance will be provided for the program
personnel should they need to travel for work-related meetings. A total of $380.25 has been
allotted for travel which 650 miles. Three laptops will be purchased for $3,000. $10,000 has
been allocated for staff development to cover expenses such as training for electronic medical
records (EMR). Purchase for additional licenses for EMR and staff identification cards. Lastly,
REDUCING MISSED PRIMARY CARE APPOINTMENTS 25
$2000 has been allotted for the purchase of telephones for personnel use. Below is the line item
budget for the innovative capstone practice.
Line-Item budget
Revenue
BCBSM Foundation Grant $25,000 - Michigan Community Health Matching
program
HHS Grant $200,000
Total Revenue $225,000
Expenses
Personnel Expenses
Program manager $104,000 - 1 FTE
CHW $52,000 - 1 FTE
Intern $2,500 - 2 Semesters
Benefits
Program Manager $16,076
CHW $10,528
Total Personnel $185,104
Operating Expenses
Travel $380.25
Laptops $3,000
Staff development $10,000
Telephone $2,000
Total Ops $15,380.25
Total expenses $200,484.25
Surplus/Deficits +$24,515.75
Table 1. Budget for The Reach-Out Program
The total cost of the program is $200,484.25, and the anticipated revenue is $225,000.
The budget is currently at a surplus of approximately $24,000. Further investigation will be
conducted to utilize the budget in full capacity to yield the best possible outcome for the
sustainability of the program. Other avenues to explore will include creating an allowance in the
budget as a secondary way to assist patients with transportation barriers. Many CHC patients
REDUCING MISSED PRIMARY CARE APPOINTMENTS 26
have transportation services through their insurance companies; however, they have been
historically unreliable (Roth, 2019). In instances where there is a transportation issue, the CHW
will be able to offer transportation assistance in the form of bus tickets or rideshare services. This
will help fill the gaps in the existing non-emergency medical transportation services.
Project’s Method for Assessment of Impact
The evaluation design is a One-group Pretest-Posttest Design. The purpose is casual
because the goal is to show the effect of the innovation on the sample. This design assesses the
dependent variable before and after the stimulus (innovative capstone practice) is introduced.
The pretest is the number of documented no-show rate prior to intervention and posttest is the
no-show rate after the intervention. The strength of the evaluation design is that it Pretest allows
us to know the difference in patient engagement after the intervention. The threats to internal
validity i.e. weakness of the evaluation is maturation and instrumentation changes. Maturation
refers to personal changes in patients’ attitudes towards primary care. Instrumentation Changes
refers to changes in EMR/EHS that can affect how a no-show is identified and documented. The
assessment tool is the patient activation measure (PAM). The short-form pam (13 question
survey item) will be used to define the patient engagement after intervention.
Plan for Stakeholder Involvement, Communication Products and Strategies
The main plan for relevant stakeholder involvement is initiating and maintaining
relationships with MPCA, healthcare providers, and CHCs. The program director will maintain
initiate and maintain partnerships with MPCA by attending relevant meetings and supporting
applicable MPCA initiatives. For the healthcare providers and CHC, the plan is to participate in
monthly meetings and provide them with free resources and training that may be available to
them in the community, which can help improve their work. Also, the board of directors for the
REDUCING MISSED PRIMARY CARE APPOINTMENTS 27
non-profit organization under which The Reach-Out Program will function will have CHC
patient population represented in the board.
The program creator/director will give presentations to its stakeholders about The Reach-
Out Program. This strategy allows the capstone innovative practice to be showcased in the real
world. A social media hashtag #ShowUpForHealth has also been created to draw awareness to
the importance of keeping primary care appointments.
How the Capstone Innovation Address Stated Problems of Practice, Negative Consequences
The innovative capstone practice addresses the stated problem of practice by identifying
missed appointments as a social problem that contributes to poor health outcomes. Also, the
innovative practice considers evidence drawn from research, interviews, and professional
experience to create an intervention that fits with the healthcare system's move toward value-
based care and consumer preference. The CHW model is evidence-based, and at this time, there
are no identified negative consequences expected from the innovation.
Conclusion, Actions and Implications
The United States is amongst the wealthiest nations in the world, yet the health of its
people are poor. When compared to other high-income peer countries, the life expectancy of
Americans is lower (Institute of Medicine, 2013). Almost half of the United States population
have at least one chronic health disease. Chronic health diseases are responsible for seven out of
ten deaths in America (Centers for Disease Control and Prevention, 2019). The problem
disproportionately affects low-income communities because they are most vulnerable to chronic
health conditions. The cause of this problem is the multi-factorial Social Determinant of Health.
The lack of emphasis on primary care and poor lifestyle choices are the most common SDOH
factors that lead to negative health outcomes.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 28
Since most chronic diseases can be prevented and treated at the primary care level (Ullah
et al, 2018), the innovative capstone practice intends to promote the need for patient engagement
in the community health system. Low-income communities are not getting the healthcare they
need due to frequently missed primary care appointments. The innovation also aims to inform the
need for specialized patient engagement strategies for the low-income community who are not
able to benefit from a high-tech digital intervention that has worked for private health clinics.
Limitations associated with the CHC system are often based on physical and financial
difficulties; however, The Reach-Out Program builds upon the CHW program to target no-
shows. Low-income communities are missing a viable service to help close the gap in healthcare
that is caused by frequently missed primary care appointments. Ethical considerations included
informed consent and confidentiality. The CHW will seek the patient’s permission before
providing the appropriate intervention to the patient. The CHW will also receive training on how
to protect patient’s health information.
The Reach-Out Program provides a patient-centered approach to eliminating this gap in
healthcare by improving the patient experience. The innovation is supported by the systems
theory and the current healthcare system’s move towards value-based care. In other, for the
innovative capstone practice to expand beyond the state of Michigan, it will operate under its
own private non-profit organization. There are grants available to implement the innovation as
well as influential internal and external stakeholders. The CHW will also be able to bill for their
services through Medicaid. The next step of the program after the pilot year is to publish findings
and expand to other CHCs in Michigan. Important stakeholders such as CHCs, healthcare
professionals, MPCA and insurance companies support the need for a patient-centered approach
to patient engagement. The ineffectiveness of the current market that address the problem
REDUCING MISSED PRIMARY CARE APPOINTMENTS 29
positions The Reach Out Program as the leading-edge tool for the social problem. As the ongoing
pandemic unravels, the CDC has reported that people who are susceptible to COVID-19 are
older adults and people of any age who have preexisting and underlying medical conditions
(Centers for Disease Control and Prevention, 2020). The preexisting conditions are conditions
that could have been prevented or treated in the primary care setting. The importance of Primary
and Preventive care may become even more an area of focus in the near future.
The initial obstacle to the implementation of the program was the possible repeal of the
ACA which was signed into law on March 23
rd
, 2010. The potential obstacle is currently not a
factor due to the ongoing pandemic. It looks like the ACA will survive its 10th anniversary. In
fact, the current administration which has threatened to repeal the ACA is now considering the
launch of a special enrollment period for people to sign up for health insurance under the ACA
(Armour, 2020). The capstone innovative practice can be immediately shared through
presentations with key stakeholders and by using the hashtags #ShowUpForHealth and
#TheReachOutProgram on social media platforms. In its pilot year, the crucial milestones The
Reach Out Program will need to accomplish is to reduce no-shows and improve patient
engagement. After the pilot year at a CHC in Detroit, MI, the findings from the implementation
will be published. Almost half of the US population has a chronic health condition. There is an
area of opportunity to change this narrative and improve health outcomes by investing in patient
engagement strategies.
REDUCING MISSED PRIMARY CARE APPOINTMENTS 30
References
Abram, T. (2018). How providers are working to stem missed appointments. Retrieved from
https://www.healthcaredive.com/news/how-providers-are-working-to-stem-missed-
appointments/527899/
American Academy of Social Work and Social Welfare (2016, September). Policy
Recommendations for Meeting the Grand Challenge to Close the Health Gap (Policy
Brief No. 2). Retrieved from https://openscholarship.wustl.edu/cgi/viewcontent
.cgi?article=1786&context=csd_research
American Academy of Social Work and Social Welfare (2018). Grand challenges of social
work: Close the health gap. http://aaswsw.org/wp-content/uploads/2015/12/180604-GC-
health-gap.pdf
Anderson, R., Sorlie, P., Backlund, E., Johnson, N., & Kaplan, G. (1997). Mortality effects of
community socioeconomic status. Retrieved from
https://www.researchgate.net/profile/George_Kaplan2/publication/30852110_Mortality_
Effect s_of_Community_Socioeconomic_Status/links/5473d0e40cf2778985abbbb4.pdf
Armour, S. (2020, March 22). U.S. Considers Special Enrollment Period for Affordable Care Act
Due to Coronavirus Spread. Enrollment period for states using federal exchange ended
Dec. 15. https://www.wsj.com/articles/u-s-considers-special-enrollment-period-for-
affordable-care-act-due-to-coronavirus-spread-11584814494
Artiga, S., & Hinton, E. (2018). Beyond health care: The role of social determinants in
promoting health and health equity. Retrieved from
REDUCING MISSED PRIMARY CARE APPOINTMENTS 31
https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-
determinants-in-promoting-health-and-health-equity/
Artiga, S. Orgera, K. & Pham, O. (2020, March). Disparities in health and health care: Five key
questions and answers. http://files.kff.org/attachment/Issue-Brief-Disparities-in-Health-
and-Health-Care-Five-Key-Questions-and-Answers
Barron, WM (1980). Failed appointments. Who misses them, why they are missed and what can
be done? Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7010402
Beaton, T (2017). How Preventive Healthcare Services Reduce Spending for Payers. Health
Payer Intelligence. Value-Based Care News. Retrieved from
https://healthpayerintelligence.com/news/how-preventive-healthcare-services-reduce-
spending-for-payers
Berkeley Human Resources (2020, March 6). Frequently Asked Question. Who is considered a
Health Care Provider? Retrieved from https://hr.berkeley.edu/node/3777
Bertalanffy, V. L., (1967). General theory of systems: Application to psychology. Retrieved from
https://journals-sagepub-com.libproxy2.usc.edu/doi/pdf/10.1177/053901846700600610
Blue Cross Blue Shield of Michigan (2018). Michigan Community Health Matching Program.
Retrieved from https://www.bcbsm.com/foundation/grant-programs/community-health-
matching.html
Burwell, S. M. (2015). Setting Value-Based Payment Goals – HHS Efforts to Improve U.S
Health Care. Retrieved from
https://mfprac.com/web2018/07literature/literature/Misc/ValueBasedPayment_Burwell.p
df
REDUCING MISSED PRIMARY CARE APPOINTMENTS 32
Centers for Disease Control and Prevention (2020). Are you at higher risk for severe illness?
Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-
complications.html
Centers for Disease Control and Prevention (2018). CDC’s Director Media Statement on US life
Expectancy. Retrieved from https://www.cdc.gov/media/releases/2018/s1129-US-life-
expectancy.html
Centers for Medicare and Medicaid Services (2017). What are CMS Star Ratings? Retrieved
from https://www.bcbst.com/docs/providers/qualityinitiatives/What_Are_CMS_Star_
Ratings.pdf
Centers for Disease Control and Prevention. (2019,October 23). Chronic Diseases in America.
Retrieved from
https://www.cdc.gov/chronicdisease/resources/infographic/chronic- diseases.htm.
Centers for Disease Control and Prevention. (2019,October 23). National Center for Chronic
Disease Prevention and Health Promotion. At a glance. Retrieved from
https://www.cdc.gov/chronicdisease/pdf/aag/nccdphp-aag-508.pdf
Cook, N., Hollar, L., Isaac, E., Paul, L., Amofah, A., & Shi, L. (2015). Patient experience in
health center medical homes. Journal of Community Health, 40, 1155-1164.
doi:10.1007/s10900-015-0042-0
Cheng, E., & Kindig, D (2012). Disparities in Premature Mortality Between High- and Low-
Income US Counties. Retrieved from https://www.cdc.gov/pcd/issues/2012/11_0120.htm
Dwyer-Lindgren, L., Bertozzi-Villa, A., Stubbs, R., Morozoff, C., Mackenbach, J., Van Lenthe,
F., Mokdad, A., & Murray, C. (2017). Inequalities in life expectancy among US counties
REDUCING MISSED PRIMARY CARE APPOINTMENTS 33
1980 to 2014. Retrieved from
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626194
Gier, J (2017, April). Missed appointment cost the U.S healthcare system $150B each year
Health Management Technology. Retrieved from https://www.healthmgttech.com/
missed-appointments -cost-u.s.healthcare-system-150b-year
Heath, S. (2017). What is the Patient Activation Measure in Patient-Centered Care? Retrieved
from https://patientengagementhit.com/news/what-is-the-patient-activation-measure-in-
patient-centered-care
Health Resource and Service Administration (2018, May). About HRSA. Retrieved from
https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html
Health Resource and Service Administration (2018, May). Federally Qualified Health Centers.
Retrieved from https://www.hrsa.gov/opa/eligibility-and-registration/health-
centers/fqhc/index.html
Heath, S. (2017). What is the Patient Activation Measure in Patient-Centered Care? Retrieved
from https://patientengagementhit.com/news/what-is-the-patient-activation-measure-in-
patient-centered-care
Institute of Medicine (2013, January). U.S. health in international perspective: Shorter lives,
poorer health (Institute of Medicine Report Brief, pg. 32). Retrieved
fromhttps://ebookcentral.proquest.com/lib/socal/reader.action?docID=3379143&query=
REDUCING MISSED PRIMARY CARE APPOINTMENTS 34
Kaplan-Lewis, E., & Percac-Lima, S. (2013). No-Show to Primary Care Appointments: Why
Patients Do Not Come. Journal of Primary Care & Community Health, 251–
255. https://doi.org/10.1177/2150131913498513
Lambert, D. (2018). Value Based Care vs. Fee-for Service. Retrieved from
https://www.carecloud.com/continuum/value-based-care-vs-fee-for-service/
Lawson, R, & Lawson, B (2008). Poverty in America: An Encyclopedia.
Lehman, U., & Sanders, D. (2007). Community Health Workers. What do we know about them?
The stated of the of the evidence on programmes, activities, cost and impact on health
outcomes of using community health workers. Retrieved from
https://www.who.int/hrh/documents/community_health_workers.pdf
McQueenie, R., Ellis, D.A., McConnachie, A., Wilson, P., & Williamson, A. (2019). Morbidity,
mortality and missed appointments in healthcare: a national retrospective data
linkage study. BMC Med 17, 2. Retried https://doi.org/10.1186/s12916-018-1234-0
Mehra A, Hoogendoorn CJ, Haggerty G, Engelthaler J, Gooden S, Joseph M, Carroll S, Guiney
PA. (2018). Reducing Patient No-Shows: An Initiative at an Integrated Care Teaching
Health Center. J Am Osteopath Assoc 2018;118(2):77–84. Retrieved from
doi: https://doi.org/10.7556/jaoa.2018.022.
Michigan Primary Care Association (2020, March 7). About Us. Retrieved from
https://cdn.ymaws.com/www.mpca.net/resource/resmgr/fact_sheets/2019_MPCA_Fact_S
heet.pdf
REDUCING MISSED PRIMARY CARE APPOINTMENTS 35
Mohammadi, I., Wu, H., Turkcan, A., Toscos, T., & Doebbeling, B. (2018). Data analytics and
modeling for appointment no-shows in community health centers. Journal of Primary
Care and Community Health Retrieved from 9, 2150132718811692.
https://doi.org/10.1177/2150132718811692
Mukherjee, J. (2017). An Introduction to Global Health Delivery. Retrieved from
http://www.oxfordscholarship.com.libproxy2.usc.edu/view/10.1093/oso/9780190662455.
001.0001/oso-9780190662455-chapter-8
National Association of Community Health Centers (2018) Community Health Center Chart
Book. Retrieved from
http://www.nachc.org/wp-content/uploads/2018/06/Chartbook_FINAL_6.20.18.pdf
National Association of Community Health Centers (2019). Community Health Center
Chartbook. Retrieved from http://www.nachc.org/wpcontent/uploads/2019/01/
Community-Health-Center-Chartbook-FINAL-1.28.19.pdf
Nuti, L.A., Lawley, M., Turkcan, A., Tian., Z., Zhang, L., Chang, K., Willis, D., & Sands, L.
(2012). No-shows to primary care appointments: subsequent acute care utilization among
diabetic patients. BMC Health Serv Res 12, 304 https://doi.org/10.1186/1472-6963-12-
304
Office of Disease Prevention and Health Promotion (2018). Social determinants of health.
Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-
determinants-of-health.
Perron, N., Dao, M., Kossovsky, M., Miserez, V., Chuard, C., Calmy, A., & Gaspoz, J (2010).
Reduction of missed appointments at urban primary care clinic: a randomized controlled
REDUCING MISSED PRIMARY CARE APPOINTMENTS 36
study. Retrieved from https://bmcfampract.biomedcentral.com/articles/10.1186/1471-
2296-11-79
Primary Care Progress (2018). The case of primary care. Retrieved from
https://www.primarycareprogress.org/primary-care-case/
Rhodes, M. L. (2012). Systems Theory. International Encyclopedia of Housing and Home.
Retrieved from https://www-sciencedirect-
com.libproxy1.usc.edu/science/article/pii/B9780080471631006895?via%3Dihub#s0010
Roth, M (2019, January). Healthcare ridesharing activity surges; focuses on improving care,
reducing costs. Retrieved from
https://www.healthleadersmedia.com/innovation/healthcare-ridesharing-activity-surges-
focuses-improving-care-reducing-costs
Solution Reach (2020, March 22). 10 Truly Awesome Ways to Reduce No-Shows. Retrieved
from https://www.solutionreach.com/blog/10-truly-awesome-ways-to-reduce-no-shows
Taber, J., Leyva, B., Persoskie, A. (2014) Why do people avoid medical care? A qualitative
study using national data. Journal of general internal medicine. Retrieved from
https://link.springer.com/article/10.1007%2Fs11606-014-3089-1
The Department of Health and Human Services, (2019). Tips and Recommendations for
Successfully Pilot Testing Your Program. Retrieved from
https://www.hhs.gov/ash/oah/sites/default/files/pilot-testing-508.pdf
The Statistics Portal (2018). Affordable Care Act - Statistics and Facts.
https://www.statista.com/topics/3272/obamacare/
Triemstra. J., & Lowery, L. (2018) Prevalence, Predictors and the financial impact of missed
Appointments in an academic adolescent clinic. Retrieved from
REDUCING MISSED PRIMARY CARE APPOINTMENTS 37
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340409/
Ullah, S., Rajan, S., Liu, T., Demagistris, E., Jahrstorfer, R., Anandan, S., Gentile, C., & Gill, A.
(2018). Why do patients miss their appointments at primary care? Journal of family
medicine and disease prevention, Volume 4 (Issue 3). Retrieved from
https://clinmedjournals.org/articles/jfmdp/journal-of-family-medicine-and-disease-
prevention-jfmdp-4-090.pdf
World Bank (2017). Life expectancy at birth, total (years). Retrieved from
https://data.worldbank.org/indicator/SP.DYN.LE00.IN
World Health Organization (2019). Chronic diseases and health promotion: Part Two. The urgent
need for action. Retrieved from
https://www.who.int/chp/chronic_disease_report/part2_ch
World Health Organization (2016). Patient Engagement. Technical series on safer primary care.
Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252269/9789241511629-
eng.pdf;jsessionid=3AA2547571F0003B50F1686AAC1CD703?sequence=1
REDUCING MISSED PRIMARY CARE APPOINTMENTS 38
Appendix A
Logic Model
Inputs
Outputs
Outcomes -- Impact
Participants Activities
Short Medium Long
What we invest?
Staff time
Staff training &
development
Funding
Partners/Stakeho
lders
Who we
reach?
Low-income
individuals /
communities
Community
Health Centers
What we do?
Patient Activation & Engagement
Reach out, Counsel, Connect,
Educate, Empower
5 patients per day
15-30 minutes encounters
Non-billable encounters
Results in terms
of learning
Awareness
Knowledge
Attitudes
Interests
Motivations
Results in terms of
changing action
Behavior (Improved
participation in primary
and preventive care)
Practice (Community
Health Center operations)
Procedures (Patient
activation and engagement
strategies)
Results in terms of change
to the conditions
1,210 patients seen in a
year
Social (patient experience
and engagement)
Environmental
(improvement of health
outcomes and life
expectancy)
Economic (decrease health
expenditures)
Approximately $242,000
generated for in CHC
revenue
Abstract (if available)
Linked assets
University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Ogunyemi, Adijat O.
(author)
Core Title
Reducing the prevalence of missed primary care appointments in community health centers
School
Suzanne Dworak-Peck School of Social Work
Degree
Doctor of Social Work
Degree Program
Social Work
Publication Date
05/20/2020
Defense Date
04/16/2020
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
missed appointments,no-show,OAI-PMH Harvest,preventive care,primary care
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Enrile, Annalisa (
committee member
), Ghosh, Subharati (
committee member
), James, Jane (
committee member
)
Creator Email
adijato@hotmail.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-313132
Unique identifier
UC11663933
Identifier
etd-OgunyemiAd-8546.pdf (filename),usctheses-c89-313132 (legacy record id)
Legacy Identifier
etd-OgunyemiAd-8546.pdf
Dmrecord
313132
Document Type
Capstone project
Rights
Ogunyemi, Adijat O.
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
missed appointments
no-show
preventive care
primary care