1. A Qualitative Study to Explore Broken Appointments at Cleveland Avenue Dental Center Holley Hooks, MPH, CPH Tracey Semcer Hope Tranberg Public Health Associates Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention 2016 PHAP Summer Seminar May 17, 2016 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

2. Overview  Significance to Public Health  Background and Objectives  Methods  Results  Conclusions and Implications for Public Health

3. SIGNIFICANCE TO PUBLIC HEALTH

4. Significance to Public Health  Broken appointments are problematic for multiple reasons  Patient does not receive care  Other patients miss opportunities for care  Dental center staff are inconvenienced  Lost revenue

5. BACKGROUND AND OBJECTIVES

6. Background and Objectives  Cleveland Avenue Dental Center  Entity of Forsyth County Department of Public Health in Winston Salem, NC  Provides low-cost dental services to community  Accepts Medicaid, NC Health Choice, and self-pay (sliding fee scale)  2015: 44.7% of all appointments were broken 1  Research question:  Why do patients break appointments? 1 Steele, D. (2016, January 01).

7. Theory of Planned Behavior 1 1 Ajzen, I. (1991). 2 Lapidos, A., Shaefer, H. L., & Gwozdek, A. (2015). 3 Lacy, N. L., Paulman, A., Reuter, M. D., & Lovejoy, B. (2004). 4 Mathu-Muju, K. R., Li, H., Hicks, J., Nash, D. A., Kaplan, A., & Bush, H. (2014). Attitude: Negative (fear 2, treated poorly 3, long wait times 3 ) Subjective Norm: Not a problem; dentist enjoys the break 3 Perceived Behavioral Control: Lack of resources (insurance, money, transportation, child care, leave from work) 3,4 Intention to Attend Appointment Appointment Attendance

8. METHODS

9. Methods  Qualitative method  Structured Interviews (15 total)  Questions based on “Why We Don’t Come” 3  Convenience sample of adults in waiting room One day per week for one month total $5 Wal-Mart gift card as compensation  General thematic analysis of data  Data analyzed by PHAP team – Holley Hooks, Tracey Semcer, and Hope Tranberg 3 Lacy, N. L., Paulman, A., Reuter, M. D., & Lovejoy, B. (2004).

10. RESULTS

11. Results  n = 14

12. Results  n = 14

13. Results - Attitudes  Fear  “I didn’t wanna come cause I felt like I didn’t floss right or I didn’t brush right or might be a cavity or I might need to get somethin’ pulled”  Low Priority  “Some people don’t have their priorities straight. They figure, ‘Well, you know, I got this service and if I don’t go today, then they gon’ reschedule me.’”  Also unnecessary, unpleasant, excuses, lack of courtesy, taking services for granted, embarrassment

14. Results - Barriers  Transportation  Work  Emergencies  Unexpected events  Forgetting  Incorrect patient phone number/address

15. Results - Norms  Dental staff inconvenienced by broken appointments  “They will be very frustrated because of course if you don’t know someone’s coming, then somebody else coulda had that slot time”  Other patients inconvenienced by broken appointments  “That’s like, kind of like a waste of time, like cause other people are also waiting to be taken back to get their teeth checked on and stuff like that”

16. Results – Why people DO come to appointments  Reminder calls and texts  TransAid  Concern for oral health  Customer service satisfaction

17. CONCLUSIONS AND IMPLICATIONS

18. Conclusions  Multiple reasons why people miss appointments  Forgetting, lack of transportation, fear, etc.  General sense of understanding that broken appointments are an inconvenience for everyone involved  There are changes that the Cleveland Avenue Dental Center can make to decrease the rate of broken appointments

19.  Limitation  Interviewed people who were at appointments – not those who broke appointments  Strengths  Diverse sample  Saturation  Learned why patients DO come to appointments Ability of dental center to make policy changes Limitations and Strengths

20. Implications  Bus passes  After hours appointments to match other health department clinics  Text reminders  Phone number and address update at registration Operations Manual

21. Acknowledgements Darlene Steele, Dr. Emily Smith, and staff of Cleveland Avenue Dental Center Naomi Lacy, Texas Tech University Health Sciences Center Tracey Semcer and Hope Tranberg

22. References  Ajzen, I. (1991). The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. doi:0749-5978/9  Lacy, N. L., Paulman, A., Reuter, M. D., & Lovejoy, B. (2004). Why We Don't Come: Patient Perceptions on No-Shows. The Annals of Family Medicine, 2(6), 541-545. doi:10.1370/afm.123  Lapidos, A., Shaefer, H. L., & Gwozdek, A. (2015). Toward a better understanding of dental appointment-keeping behavior. Community Dent Oral Epidemiol Community Dentistry and Oral Epidemiology, 44(1), 85-91. doi:10.1111/cdoe.12193  Mathu-Muju, K. R., Li, H., Hicks, J., Nash, D. A., Kaplan, A., & Bush, H. (2014). Identifying Demographic Variables Related to Failed Dental Appointments in a University Hospital- based Residency Program. Pediatric Dentistry, 36(4), 296-301. Retrieved April 27, 2016.  Steele, D. (2016, January 01). [Broken Appointments Report]. Unpublished raw data.

23. For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: OSTLTSfeedback@cdc.govWeb: http://www.cdc.gov/stltpublichealthOSTLTSfeedback@cdc.govhttp://www.cdc.gov/stltpublichealth The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Holley Hooks, MPH, CPH lhi6@cdc.gov Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support