Why Impoverished Patients Skip Their Visits


In the East Orange Hospital Clinic (Carewell Health Medical Center), most beneficiaries represent the impoverished population, and the problem of skipping follow-up appointments has recently occurred. The issue is related to the clinical practice as the patients lack education about the importance of follow-up visits, cannot communicate their needs or do not receive additional reminders. Consequently, sustainable change can be achieved through the intervention of physicians, practitioners, and administrators operations (Dantas et al., 2018). This assignment addresses the concepts of change in practice to influence patients’ behavior and decision-making, area of interest identification, and literature review with recent studies about the impoverished population and healthcare. Furthermore, recommendations based on the practical intervention experience are presented and explained regarding outcomes for patients and stakeholders.

Practice Issue Description

A change in the impoverished patients’ perception of follow-up appointments is complicated and includes multiple aspects that require revision. The area of interest is broad because the strategies to change clients’ behavior can then be used to solve future challenges. Indeed, problems with specific populations might occur in NP practice if the beneficiaries of an organization have particular needs or socio-economic statuses (Curley, 2020). Patients skip appointments for multiple reasons, and practitioners can impact their decision-making to improve the situation. The concept of population-based problem-solving must address specific characteristics, and for impoverished clients, the costs of transportation, insurance, and priority setting are to be considered (Curley, 2020). Furthermore, the practice problem is severe because missed follow-ups damage the effectiveness of treatment, making additional financial burdens if the clients’ conditions worsen.

Practice issue: Areas of Interest for NPs

Interacting with patients is simultaneously an advantage and a challenge for nursing practitioners because the outcomes are difficult to predict. NPS must identify why the impoverished beneficiaries refuse to re-attend their physicians retrieve the aspects they can influence, develop and implement solutions in their interaction with patients. Conducting research and a literature review is a workable strategy to gather sufficient evidence necessary for decision-making. Impacting the patients’ behavior and perception of healthcare services perception is important for nursing practitioners in terms of advocacy for better patient outcomes (Williamson et al., 2021). Indeed, the quality of services will increase if the clients follow their doctor’s instructions and are educated enough to complete their treatment correctly. Furthermore, practical intervention requires involving other team members, such as practitioners and administrators, enabling the NPs to apply project management, communication, and leadership skills.

Intervention Outcomes

The problem is urgent because the growing number of skipped follow-up visits signals lower satisfaction with the quality of the services. The lack of additional examination negatively influences the initial treatment outcomes and worsens patients’ conditions. Consequently, they will have to return to the hospital, and the costs for it would be much higher than for attending a follow-up visit on time. It will result in a financial burden not only for the impoverished clients but also for the organization that will have to organize services and human resources for treatment (Dantas et al., 2018). The practical intervention to influence the beneficiaries’ behavior should contain updates on doctors’, nurses’, and administrators’ actions. Indeed, physicians can improve patient education by teaching how crucial it is to attend an appointment; administration can develop reminder practices (Ofei-Dodoo et al., 2019). Nursing practitioners can also adjust their communication to tailor the importance of follow-up visits and ensure that the client understands.

The PICOT Question

The identified population tends to prioritize saving finances and affording only the minimum of healthcare services even when their conditions require more complicated interventions (Ofei-Dodoo et al., 2019). Intervention for skipping follow-up visits must be based on the research about the population and include multiple influence channels, such as patient education, notification, and communication simultaneously. In comparison, another solution can be no actions taken on the practicum site’s workers, yet patients’ worsening conditions due to the skipped appointment can be explained as their responsibility. The outcome is a decrease in missed follow-up visits by the impoverished populations, and it can be calculated through attendance tracking from the electronic record system. Timeframe to realize the initiative and achieve notable results depends on the number of follow-up visits assigned by physicians to their impoverished patients, and the averagely sufficient period is two months.

Literature Review

Modern scholarly articles reveal that the reasons for the impoverished populations to skip the follow-up appointment are specific and address their financial abilities and life priorities. The lack of attendance occurs due to clients’ forgetfulness, language barrier, insufficient funds for transformation, lack of education, and understanding of follow-ups’ importance are the main reasons for skipping a visit (Arpey et al., 2017). Research conducted in 2018 emphasized the urgency of the practice issue as the results revealed that the average rate of missed return visits is 23%, and it is damaging the healthcare industry’s performance (Dantas et al., 2018). The researchers’ statistics can be used as an argument to encourage organizations’ workers to implement the change and influence the problematic situation.

The scope of literature about the selected issue also suggests that practitioners can update their communicational approaches and visit protocols and include relevant patient education to influence the beneficiaries’ decision-making. Shrestha et al. (2017) conducted a study and stated that “missed clinic appointments reduce clinic efficiency, waste resources, and increase costs; limited data exist on subspecialty clinic attendance” (p. 436). Practitioners can motivate the clients by explaining the outcomes of skipping visits, the treatment price if the worsening conditions were not timely addressed, and improving organizational strategies such as phone reminders.

Recent studies’ prevalent themes and concerns address the need to consider patients’ backgrounds and population characteristics to understand what motivates them to misbehave. For instance, Ofei-Dodoo et al. revealed why patients skip their appointment and can be used as evidence for developing an intervention to change their behavior (Ofei-Dodoo et al., 2019). Furthermore, Aragona et al. concluded that the follow-up visits problem exists and provided evidence that socio-economic difficulties also influence the patients’ attendance (Aragona et al., 2020). Articles also described the impact of the COVID-19 pandemic on how specific groups of patients attend the hospital and what prevents them from doing it as prescribed.

Scientists studied the availability of healthcare services worldwide, and the experiences of diverse populations in different countries were a valuable source of evidence about skipping follow-ups issue urgency. A study conducted by George et al. explored the Romanian clinics’ operations and discovered that decreased access to care occurred due to financial, structural, and cognitive barriers, such as health insurance expenses (George et al., 2018). The unique insight gained from the literature review is that the misperception of the healthcare services and prescriptions importance is the problem of many populations, and it can be addressed through practical change.

Evidence-Based Recommendations

Evidence gathered from the research revealed that patient education, communication, and notification are the aspects that required revision and enabled the practitioners, physicians, and administrators of our unit to change their practice. Nurses described the low engagement with healthcare recommendations as harmful behavior, encouraging the patients to avoid it and complete their treatment with all appointments (Williamson et al., 2021). Physicians updated their communicational approaches, included the description of additional expenses if treatment results are not checked on time, and developed further recommendations for impoverished patients. Administrators increased the number of notifications through phone calls and email reach and provided the beneficiaries with the telemedicine option to contact the physician for consultancy without fees. In three weeks, a meeting with the preceptor and the team was organized to evaluate the effectiveness of the implemented measures and adjust them based on patients’ and participants’ feedback.

Intervention Stakeholders

Stakeholders interested in addressing the issue are primarily the physicians whose patients refuse to attend the clinic. Furthermore, the clinic’s quality improvement team may find the initiative worth adding to the practices. Indeed, attendance regulations will positively impact treatment outcomes and decrease the number of worsened chronic disease conditions (Williamson et al., 2021). Patients also participate in the intervention development as a part of the project to gather feedback from them and explore their values and knowledge about the importance of follow-up visits.

Recommendation’s Fit, Feasibility, and Appropriateness

The requirement to address the intervention’s fit, feasibility, and appropriateness occurred before the actual practice change implementation because multiple participants were involved. The update in patient education, communication, and notification was applicable in the current clinical infrastructure; thus, additional recourses such as workforce and finances were found and implemented quickly. The feasibility and appropriateness of practical intervention were proven by gathering patients’ initial feedback about their awareness of follow-up visits’ importance (Dang & Dearholt, 2017). Indeed, most of them did not know about the outcomes and costs of skipped appointments, and new information will influence their decision-making.


The number of missed appointments decreased by 12% in 8 weeks; thus, the activities performed to address the issue were efficient. Then, the awareness of the follow-up visits importance improved through each patient’s education adjusted to their population values and characteristics. The increasing number of missed appointments noticed by a practitioner and developed into a significant change in treatment is an example of how evidence-based initiatives can impact healthcare (Curley, 2020). The practical intervention to influence patients’ behavior through updating education, communication, and notification led to significant positive change in healthcare services’ perception and improved the quality of operations.


Aragona, M., Barbato, A., Cavani, A., Costanzo, G., & Mirisola, C. (2020). Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties. Public Health, 186, 52-56. Web.

Arpey, N. C., Gaglioti, A. H., & Rosenbaum, M. E. (2017). How socio-economic status affects patient perceptions of health care: a qualitative study. Journal of Primary Care & Community Health, 8(3), 169-175. Web.

Curley, L. A. (2020). Population-based nursing: Concepts and competencies for advanced practice (3rd ed.). Springer Publishing Company.

Dang, D., & Dearholt, S. (2017). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed). Sigma Theta Tau International.

Dantas, L. F., Fleck, J. L., Oliveira, F. L. C., & Hamacher, S. (2018). No-shows in appointment scheduling–a systematic literature review. Health Policy, 122(4), 412-421. Web.

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