Successes and Challenges of Scheduling Home Health Visit Appointments

Publication Details

Operational Successes

Although overall participation was relatively low among those initially asked to participate in NHIS FHS, most participants who gave permission for their contact information to be passed to study staff scheduled an appointment (207 of 354, 58.5%), and of those who scheduled a home visit, most completed a home examination (85.0%, n = 176) (Figure 2).

As shown in Table 8, the case information for more than three-quarters of the 354 participants who agreed to be contacted (79.4%, n = 281) were delivered to study staff within 7 days after the NHIS interview. Nearly all cases (97.2%, n = 344) were delivered within 14 days. Only 10 (2.8%) were delivered more than 2 weeks after the NHIS interview, of which, 9 were delivered 15–21 days after and 1 was delivered more than 22 days after (see “Operational Challenges”).

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Table 8

Number of days between National Health Interview Survey interview and receipt of case information by study staff, and percentage of cases who ultimately scheduled follow-up home examination

Study schedulers spoke with 198 of the 354 Sample Adults (55.9%) who gave permission for their contact information to be shared within 5 days of the initial phone attempt. Of those 198, about one-half scheduled an appointment during the first successful phone contact and completed the home examination without the need for a follow-up mailing.

Regardless of outcome, study staff made the minimum three phone contact attempts for most cases, and more phone contact attempts for some cases. Table 9 shows the percentage of cases that received less than three, three, and more than three phone contact attempts by final status. Among Sample Adults who scheduled a home examination but did not complete it, 100% received more than three contact attempts. Among Sample Adults who completed a home examination, 24.2% (n = 43) received less than three contact attempts, 14.2% (n = 25) received three, and 61.4% (n = 108) received more than three. Among Sample Adults who spoke to study staff but never scheduled a home examination, nearly all (93.5%, n = 43) received more than three. Among Sample Adults who never spoke with study staff, 100% received more than three phone contact attempts.

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Table 9

Number of phone contact attempts, by type of participation in National Health Interview Survey Follow-up Health Study

All the telephone numbers provided by Sample Adults were in service (as determined by ringing status), and all answered calls were answered by someone in the home of the Sample Adult. Everyone who was supposed to be mailed a noncontact or refusal packet was mailed one, and everyone who qualified for an e-mail or text message was sent one. Twelve of the 264 e-mail addresses provided returned notification that the message could not be delivered (4.5%).

During the initial weeks of the data collection period, Westat reviewed the contact records to ensure the schedulers had documented contact attempts accurately. Scheduler errors were minimal. Those that occurred were identified and corrected quickly.

As shown in Table 10, while 44.0% of the initially scheduled appointments were eligible for reschedule (91 of the 207), most of these were rescheduled and ultimately completed. One-quarter of the 91 eligible-for-reschedule initial appointments (n = 23) never rescheduled either because the scheduling staff could not reach the Sample Adult, or the Sample Adult refused to reschedule. Most, at 74.7% (n = 68), did reschedule, and most of these, 88.2% (n = 60), ultimately completed their home examination.

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Table 10

Information about rescheduled National Health Interview Survey Follow-up Health Study home examination appointments

As a result of the rescheduling efforts and creative problem solving by the study team, 15 difficult-to-schedule home visits were completed 50 days or more after the interview, instead of not occurring at all. Ten of these outliers were situations where the visit was rescheduled one or more times, including three refusals that were successfully converted and two cases that were a no-show for an appointment. The remaining five cases included a participant who was temporarily living out of state for 3 months and returned shortly before the end of the field period; a participant who said they were very busy and requested a recontact several weeks later; two participants for whom arrangements were made for a health representative to drive more than 500 miles round trip to conduct the examination because the health representative who lived in their location was unavailable; and one participant who required a Sunday appointment but was difficult to schedule due to work travel.

As shown in Table 11, among the 176 Sample Adults who completed a home examination, 62.5% (n = 110) said scheduling their appointment was very easy and 32.4% (n = 57) said it was easy; 4.5% (n = 8) said it was difficult and less than 1.0% (n = 1) said it was very difficult .

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Table 11

Burden of scheduling among National Health Interview Survey Follow-up Health Study participants who completed a home examination

Major Operational Challenges

Appointment Scheduling Delays

A delay between introduction and appointment scheduling always occurred because the Sample Adult and FR could not schedule the FHS home examination during the NHIS interview. As described in “Case Data Transfer,” the Sample Adult had to give permission to pass their contact information to Westat’s subcontractor, and ExamOne could not schedule the appointment until the Sample Adult’s contact information was loaded into ExamOne’s computer system. This process usually took between a few days and a week, although sometimes longer if the FR was delayed in transmitting their cases. On average, Westat received cases 6 days after the NHIS interview. The schedulers made their first phone attempt 7 days after the interview, it took another 3 days before they actually spoke to the participant, and 3 more days until the phone contact resulted in scheduling an appointment.

As shown in Table 8, Westat received 79.4% of the cases (n = 281) within 1 week of the NHIS interview, 17.8% of the cases (n = 63) between 8 and 14 days after the interview, and 2.8% of the cases (n = 10) 15 or more days after the interview. Cases received within 1 week and between 1 and 2 weeks after the interview had similar likelihoods of scheduling a home examination (58.4% and 60.3%, respectively). While a lower percentage of the cases received more than 2 weeks after the interview (longer than the protocol specified) scheduled an examination (50%, n = 5), this was a minor issue because so few cases fell in this category.

Nudge theory suggests that minimizing the barriers to a desired action is a key to raising the likelihood of response (11). However, this scheduling process did the opposite, by introducing notable barriers. Even if the Sample Adult wanted to call to make an appointment at the time of the NHIS interview, they could not. For this reason, the phone number printed in the study brochure was not the number of the ExamOne scheduling office, but rather a line answered by NCHS staff. In practice, no Sample Adults called this NCHS number to get more information about the study. Only one person called it asking to schedule an appointment (the spouse of the Sample Adult who had given permission to be contacted and who wanted to participate themselves but were ineligible to do so).

Making Contact

The most common type of nonparticipation—“never spoke to study staff”—was the result of the main challenge in scheduling: the inability of the scheduler to contact potential participants. In order to schedule the appointment, the scheduler had to speak with the Sample Adult on the phone. As explained previously, most Sample Adults who gave permission for their contact information to be passed on to the schedulers but who never completed the examination never spoke with a scheduler. This was the case even though the schedulers called multiple times and sent e-mails and text messages to all those who agreed to be contacted by those methods, along with the noncontact letter and brochures. These Sample Adults did not answer the phone when the schedulers called, never sent an e-mail, and never called the scheduling line. The noncontact mailing may have helped some, but of the 197 Sample Adults who were sent a noncontact mailing, nearly one-half (47.2%, n = 93) never spoke with a study staffer and three-quarters (76.6%, n = 151) never had an examination.

Too-short call window

The postrefusal, noncontact-letter, 3-day call window, suggested by Westat during the planning process, was shorter than the initial 5-day call window. The recruitment specialists reported that the 3-day window to complete their calls made it difficult to complete calls during the Sample Adult’s preferred days of the week, or to follow up with cases that requested a specific callback time because Westat’s computer system removed the case from their call list after the window had closed. This may have contributed to the high no-contact rate.

Maximum Contacts

The second most common type of nonparticipation—"maximum contacts"—was a result of the second challenge: the tendency of some Sample Adults to interact with schedulers by speaking with a scheduler but not scheduling or scheduling but not completing an examination, without ever outright refusing. These respondents often gave evasive answers when schedulers called, until the maximum number of contacts allowed by the protocol was reached, and did not reschedule appointments after they had been canceled by either the Sample Adult or the health representative.

Refusals

The third most common type of nonparticipation—"refusals"—was a result of the third challenge. Some Sample Adults refused before scheduling an appointment, while others refused after scheduling. The refusal letter and refusal converters had limited success with conversion. Of the 25 cases who refused at some point and were sent the refusal mailing, 5 ultimately completed the examination; the rest had a final status of refusal.

Inadequate training in convincing reluctant Sample Adults to participate

As described in previous sections, the segment of the training for the schedulers and recruitment specialists on convincing reluctant respondents to participate was short, with minimal opportunity for practice. This skill was not assessed as part of the post-training assessment of scheduler readiness. This may have played a role in the high rate of maximum contacts and refusals.

Rescheduled appointments

In total, 91 cases were eligible for reschedule. In some cases, only the participant was responsible for the need to reschedule, in some cases only the health representative was responsible, and in some cases both were responsible. The numeric results are shown in Table 10.

Only the participant was responsible for the need to reschedule in 52.7% of the 91 cases eligible for reschedule (n = 48). Many participants did not explain why they needed to reschedule, particularly those who called the toll-free number to change their appointment. The health representatives were more likely to obtain a reason if the person canceled in response to the appointment reminder call. Work or other scheduling conflicts were common reasons, and a few participants forgot about the appointment or did not answer the door when the health representative visited, even after confirming with the health representative.

Only the health representative was responsible for the need to reschedule in 30.7% of the 91 cases eligible for reschedule (n = 28). An additional 16.5% of the 91 reschedule-eligible cases (n =15) were rescheduled more than once, with the health representative and participant each responsible for at least one instance of rescheduling eligibility. These cases are not counted in either the participant-only-initiated or the health representative-only-initiated reschedules. Health representatives rescheduled due to illness, car trouble, and scheduling conflicts that arose after the appointment was scheduled. In a few cases, the health representative was double-booked by mistake, and one of the visits had to be rescheduled. A few visits had to be rescheduled due to computer problems, mainly at the start of data collection. There were also six instances where the health representative was unaware of a scheduled appointment. In one instance, the health representative failed to mark the missed appointment on their personal calendar. One missed appointment was transferred to a different health representative and the scheduler failed to inform the health representative that the case had been reassigned to them. Three of the missed appointments occurred because the case did not download to the health representative’s laptop during a data transfer. In another instance, the health representative had been texting back and forth with the scheduler about appointments for two different cases and mixed up the dates.

In the first few weeks of data collection, the contractor instituted procedures to minimize the possibility that visits would have to be rescheduled due to operational factors (health representative unaware of the appointment, case did not download, double-booking, etc.). When the schedulers made an appointment for the participant’s home examination visit after confirming the health representative’s availability, they sent the health representative a text message or e-mail notifying them that the case had been assigned. Health representatives were instructed to conduct a data transmission to pick up the case within 24 hours and confirm that the case had downloaded to their computer. Additionally, the ExamOne supervisor reviewed the scheduling system to identify upcoming appointments and sent health representatives a reminder text message or e-mail 3 days before their scheduled appointments.

Minor Operational Challenges

Inability of Recruitment Specialists to Schedule Appointments

Because the Westat recruitment specialists did not have access to the ExamOne portal or calendar where ExamOne phlebotomists documented their availability, only ExamOne schedulers could identify an available health representative and schedule the home visit. As a result, if and when a Westat recruitment specialist reached a Sample Adult who was willing to schedule, they had to add the scheduler to the phone call via conference call. They encountered a few instances where the call dropped and they were unable to get the scheduler back on the line, or they were put on hold and eventually transferred to voicemail and had to leave a message. The recruitment specialists reported this experience was frustrating for them and for the Sample Adult. However, it was not a primary reason why refusals did not schedule appointments.

Difficulty Finding Available Health Representative

Health representatives were not always available on the days and at times requested by Sample Adults. If the participant requested specific dates, days of the week, or times of day on which no health representative was available, the scheduler tried to contact and identify one who could accommodate the participant’s preferences. Also, when participants wanted appointments further out because of vacation or travel plans, and the health representatives had not yet entered their availability for that time period, the scheduler had to contact health representatives to find one who was available. Even if the scheduler identified a health representative who was available at the selected time, sometimes it took several follow-up calls to finalize the appointment. Occasionally the participant was no longer available on the dates they had requested, and the scheduler had to begin the process again. Of the 44 cases with a final status of maximum contacts, 9 cases (20.5%) included scheduler contact with the participant, an attempt to locate an available health representative, and no subsequent contact with the participant, despite attempts. Of these nine, six were Sample Adults who had called into the scheduling line. While this was not a common problem, it prevented nine willing Sample Adults from participating.

Preferred Contact Times Initially Not Displaying Correctly

Although the preferred contact times were collected and transmitted to study staff accurately, it was discovered 3 weeks into the field period that the computer system was displaying mornings as the preferred contact time for all cases, regardless of the Sample Adult’s actual preference. The contractor fixed this issue the same day so that the preferred contact times displayed correctly for all cases and subsequent call attempts were placed at these preferred times whenever possible.

Scheduling Challenges Identified by Participants

Of the 66 participants who responded that scheduling their appointment was anything other than “very easy” (Table 11) and were asked how the appointment scheduling could be improved, one-half did not offer any suggestions.

Among participants who provided feedback, the scheduling challenge identified most often was the lack of alternative scheduling modes. About one-third of those providing a response to this question would have liked an alternative to scheduling by phone. Others suggested the ability to schedule online, through text message, or through e-mail. While it is unknown how many, if any, Sample Adults (among those who ultimately participated and those who did not) would have used these other scheduling methods if they had been available, it is notable that the most common suggestion for improving the scheduling process was an alternative to scheduling by phone.

Other challenges identified by participants included the initially unidirectional scheduling process, difficulties rescheduling, poor communication about rescheduling, and limited appointment options. Some participants suggested including the scheduling number on the initial brochure so they could call to make an appointment instead of waiting for the scheduler to contact them. Other participants indicated they did not know which number to call if they had to reschedule or reported having difficulty reaching the health representative to reschedule. One participant expressed frustration that the health representative failed to keep the appointment and they were not contacted in advance that the visit needed to be rescheduled, and another participant would have liked better communication about why a visit was rescheduled twice. Others noted that health representative availability was limited, and they would have preferred more options for appointment dates or times.

Unexpectedly, answers to the question on the post-examination survey about suggestions for making the home visit easier and more convenient were also all about scheduling challenges. Of the 44 participants asked this question (see “Conducting the Home Health Examination, Operational Successes”), only a few offered suggestions, but all those suggestions related to appointment scheduling. They suggested having more weekend appointment slots, reducing the amount of time on hold when calling the scheduling number, and having the option to schedule via text messaging.

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