Using Short Message (SMS) to Deliver Appointment Reminders and Reduce No-Show Rates: An Evidence-Based Practice Project

Background/Objectives: Missed appointments (MAs) are correlated with reduced treatment efficacy, increased financial burden on medical institutions, and early treatment terminations for therapy (DeFife, Conklin, Smith, & Poole, 2010). MAs occur for a variety of reasons including, but not limited to severity of illness, financial/geographic constraints, and forgetting the appointment (Filippidou, Lingwood, & Mirza, 2014). Appointment compliance within outpatient mental health clinics has a wide variance with some clinics reporting MAs ranging from 15% to 50% (Car, Gurol-Urganci, de Jongh, Vodopivec-Jamsek, & Atun, 2013). With decreasing costs and a subsequent massive increase in mobile phone technology use by the general population, Short Message Services (SMS) has become a new mainstay for direct communication (Brown et al., 2018). Availability of SMS in America is so high that traditionally at-risk populations such as the homeless have access to SMS through the use public outreach programs and prefer SMS reminders (Moczygemba, et al., 2017). These appointment reminders have been implemented in a large variety of clinical settings including, but not limited to outpatient mental health, radiology, physical therapy, and dentistry with each setting experiencing a significant decrease in MAs (Boksmati, Butler-Henderson, Anderson, & Sahama, 2016). Design: The Iowa model is optimal for this project with interventions tailored to best suite an organization with multiple departments invovled. Setting: At Outpatient Psychiatric Services-Hillcrest (OPS-H), the MAs rate is 18% among Mental Health Nurse Practitioners (MHNPs) and 33% with therapy appointments. OPS-H uses the Voicevox automatic phone call service reminder for appointments and on September 2018 began mailing patient orientation packets to new patients with driving directions, policy details, and procedure information. Participants: OPS-H patients seen by PMHNPs and their students for medication management and therapy with both initial intakes and follow-up appointments. Intervention: University of California San Diego (UCSD) and University of San Diego (USD) Institutional Review Board (IRB) approval were obtained and qualitative statements from PMHNPs and staff regarding attitudes and barriers regarding SMS were gathered. Pre-data collection surveying MAs rates and SMS sign up among PMHNP patients for the previous 8 weeks was conducted. After pre-data collection was complete, 15 to 30-minute teaching sessions took place with PMHNP, PMHNP students, and front desk staff. Flyers informing about SMS services were posted in patient waiting rooms. Data was collected weekly for a minimum of 8 weeks with an examination of SMS sign up rates and MAs, along with provider/staff SMS compliance with offering SMS to patients. At the end of the data collection, qualitative statements regarding attitudes and responses to SMS were gathered from PMHNP, PMHNP students, and front desk staff. Throughout the project, data was continually collected on secured cloud and local hard drives with continual tallies on Excel spreadsheets. Case identifiers were limited to alpha numeric codes with no personal information attached. Measurements: PMHNP and PMHNP student patient no show and SMS sign up rates were collected from August to November 2019. Results: SMS sign ups increased from 23% to 61%, attaining statistical significance. MA rates decreased from 15% to 11%, while approaching statistical significance. Conclusion: SMS appointment reminders are favorable to the majority of OPS-H patients. SMS is a cost effective and efficient tool to hep prevent MAs or no-shows. SMS can be beneficial toward decreasing MAs or no-shows. Key Words: SMS, Text-messages, Appointment-reminders, No-shows, Missed Appointments, mobile phones, smart phones

Using Short Message Services (SMS) to Reduce No-Show Rates an Evidence-Based Practice Project

Abstract Background: No-shows (NS) are correlated with reduced treatment efficacy, increased financial burden on medical institutions, and early treatment termination for therapy. NS occur for a variety of reasons and appointment compliance within outpatient mental health clinics has a wide variance with clinics reporting no-shows ranging from 15% to 50%. This section of the project is a continuation started by an earlier USD DNP student Fernando Serrano, in which the projects aims were expanded beyond the participation of nurse practitioners only to now include marriage family therapists (MFT), psychologists and medical residents, and to address the NS rates clinic-wide. One year after the initial project was implemented, the year-to-date no-show rates for the entire clinic was 11.40%. For residents it was 12.58%, for nurse practitioners (NP) it was 5.71%, and for MFTs and psychologists it was 12.82%. Purpose of the Project: Providers and staff will offer patients the ability to sign up for Short Message Services (SMS) appointment reminders. Patients who agree to SMS will receive text messages to their phone with an appointment reminder on the day prior. The goal is to increase SMS use with patients and reduce missed appointments (MA) by 20% clinic-wide and within each group of clinicians. Framework/EBP Model: The IOWA model was used for this project. Evidence-Based Intervention: With continual reduced cost and substantial increase in mobile phone technology usage by the general population, SMS has become a new mainstay for direct communication. SMS appointment reminders have been successfully implemented in mental health, radiology, physical therapy, and dentistry with each setting experiencing a significant decrease in no-show rates. Implementation: After clinic and university IRB approval, SMS teaching material, printouts and reminder notes for providers were prepared. Qualitative statements from the three disciplines about attitude and barriers regarding SMS collected before, during and after the project’s implementation. Pre-data collection included surveying MA rates among all clinic patients for the previous 8 weeks. 15-30-minute teaching sessions took place with psychiatric mental health nurse practitioners (PMHNP), PMHNP students, MFT’s, psychologists, residents, and administration staff. SMS “How to” flyers posted in provider communal areas and in each provider room to instruct and remind providers and staff to offer SMS reminders to patients. Data was collected weekly for 8 weeks examining MAs and provider/staff SMS compliance with offering SMS to patients. Data was continually collected on secured hard drives on excel spreadsheets. Data was generated from reports without any patient identification information. Evaluation Results: We expected at least 50% of the providers/students/staff would report they are offering SMS to patients at the end of the first 4 week and at least 75% by the end of 8 weeks. We predicted at least 70% SMS signup with patients and a reduction in no-show rates by 20% upon project completion. Implications for Clinical Practice: We anticipated all providers and staff at the clinic would offer SMS sign up as a part of standard policy and procedure. As SMS sign ups grows, NS will decrease. With a further decrease in clinic wide no-show rates, this program could possibly be rolled out to other UCSD clinic sites. Conclusions: The brevity, efficiency and cost-effectiveness of SMS allows patients to quickly be reminded of upcoming appointments with the choice to confirm or reschedule as needed. SMS helps increase appointment attendance while reducing provider nonproductive hours from no-shows

Feasibility of Cell Phone Surveys in People with Mental Illness Experiencing Homelessness During COVID-19

People experiencing homelessness (PEH) may be at increased risk for negative physical and mental health outcomes in the context of community spread of COVID-19. Research into the impacts of COVID-19 on this vulnerable population can be affected by inaccessibility and poor engagement resulting in minimal representation in population-based survey data. The increased use of mobile phone technology (mHealth) to provide medical and psychiatric care during the COVID-19 pandemic could provide an effective platform for gathering data from this hard-to-reach group. This paper examines feasibility, via review of the barriers and facilitators, of using a mobile phone intervention to administer a series of surveys. Data collected via mHealth includes health behaviors and health awareness, access to services, and mental health symptoms in the context of the COVID-19 pandemic among a sample of 30 PEH. At the end of the six month study, 11 (36.7%) participants completed the full study protocol while 19 (63.3%) partially completed the study. There was a significant difference in completion rates based on whether participants were unsheltered-homeless or sheltered-homeless. The study was rated highly by fully compliant participants in measures of acceptability and usability. Applying principles learned in this pilot study to develop feasible, usable and acceptable means of data gathering through the use of mHealth, can have wider ramifications outside of COVID-19

The Effects of Affective Arousal on Intentions to Engage in Sexual-Risk Behavior: An Experimental Study

Despite decades of research on correlates of condom use, and numerous intervention development studies, condom use behavior remains inconsistent among adolescents and emerging adults as the incidence and prevalence of sexually transmitted infections continues to rise. One factor that may play a role in risky sexual decision-making is state affect, however, research investigating this relationship is equivocal. Therefore, the goal of this study was to examine the effects of experimentally induced affective arousal and affective valence on intentions to engage in condomless sexual activity in a sample of emerging adults. Based on the dual systems model of youth decision-making, it was hypothesized that participants randomized to the high affective arousal conditions would report greater intentions to engage in condomless sexual activity than participants randomized to the low affective arousal conditions. In addition, it was hypothesized that there would be no differences in intentions to engage in condomless sexual activity between participants randomized to the positive or negative valence conditions. Participants included heterosexual-sexually active emerging adults who reported not being in a monogamous romantic relationship (N = 136). Results did not support the hypothesis predicting a main effect of affective arousal, however, the hypothesis predicting no main effect of affective valence was supported. This study provides the first experimental data about the relationship between affective arousal and affective valence on risky sexual decision-making. Findings suggest that stable individual-difference factors may be more strongly associated with sexual risk behavior than situational and contextual factors

Development of a Combined Model of College Student Alcohol-associated Condomless Sex

Harmful alcohol use and sexually transmitted infections (STIs) are significant public health concerns for college students. Because alcohol use and condomless sex often co-occur in this population, alcohol-associated condomless sex has been identified as a target for behavioral interventions. Existing theoretical frameworks have not garnered sufficient empirical support to serve as the foundation for interventions. The primary goal of the current study was to use a mixed-methods approach to develop a novel model of college student alcohol-associated condomless sex that combines elements from well-established health behavior theories. In Aim 1, multilevel structural regression models were estimated to predict condomless vaginal intercourse in a sample of sexually-active college student drinkers (N = 57). An Exploratory Aiminvestigated the extent to which the model estimated in Aim 1 fit sexual activity occurring prior to the COVID-19 pandemic (N = 128). Aim 2 consisted of in-depth-interviews with a sub-sample of participants (n = 18) to gather perceptions about the role of alcohol in sexual activity and identify additional constructs pertaining to college student condom use. Quantitative results demonstrated the best-fitting model explained a significant proportion of variance in condomless vaginal intercourse at the between- and within-person level. Themes derived from the in-depth-interviews identified supplemental components of condom use decision-making. Findings from both aims were synthesized to construct a preliminary combined model of alcohol-associated condomless sex. This model can be refined in future work and ultimately serve as the theoretical foundation from which to develop a combination alcohol-STI prevention-intervention tailored to college students

Mobile phone use in chronic diseases education and awareness in rural Kenya

Philosophiae Doctor - PhDThis study set out to develop an integrated model that could explain the sustainable adoption of mHealth, among the rural populations. With a penetration level of 130%, the ubiquitous mobile phone infrastructure was conducive to implementing mHealth even in the remote and rural regions of Kenya, which otherwise grapple with inequality and inequity of the healthcare system and a rising chronic diseases burden. Whereas mHealth could provide a suitable low-cost solution to disseminate targeted education to the grass-root masses in a short time, its uptake was reported to be low and short- lived. Therefore, the purpose of the study was to evaluate the factors that could explain the low levels of mHealth adoption for education on chronic diseases in the rural settings of the country. From a theoretical perspective, a combination of four social behaviour change theories, three technology adoption models, and two health behaviour change models guided the development of the theoretical framework. Seven factors were subsequently tested: perceived susceptibility, perceived severity, perceived usefulness, perceived ease of use, social influence, age, and language literacy, all of which measured mobile phone use for health literacy. Thirteen hypotheses were formulated from these factors

Challenges and solutions implementing an SMS text message-based survey CASI and adherence reminders in an international biomedical HIV PrEP study (MTN 017)

BackgroundWe implemented a text message-based Short Message Service computer-assisted self-interviewing (SMS-CASI) system to aid adherence and monitor behavior in MTN-017, a phase 2 safety and acceptability study of rectally-applied reduced-glycerin 1% tenofovir gel compared to oral emtricitabine/tenofovir disoproxil fumarate tablets. We sought to implement SMS-based daily reminders and product use reporting, in four countries and five languages, and centralize data management/automated-backup.MethodsWe assessed features of five SMS programs against study criteria. After identifying the optimal program, we systematically implemented it in South Africa, Thailand, Peru, and the United States. The system consisted of four windows-based computers, a GSM dongle and sim card to send SMS. The SMS-CASI was, designed for 160 character SMS. Reminders and reporting sessions were initiated by date/time triggered messages. System, questions, responses, and instructions were triggered by predetermined key words.ResultsThere were 142,177 total messages: sent 86,349 (60.73%), received 55,573 (39.09%), failed 255 (0.18%). 6153 (4.33%) of the message were errors generated from either our SMS-CASI system or by participants. Implementation challenges included: high message costs; poor data access; slow data cleaning and analysis; difficulty reporting information to sites; a need for better participant privacy and data security; and mitigating variability in system performance across sites. We mitigated message costs and poor data access by federating the SMS-CASI system, and used secure email protocols to centralize data backup. We developed programming syntaxes to facilitate daily data cleaning and analysis, and a calendar template for reporting SMS behavior. Lastly, we ambiguated text message language to increase privacy, and standardized hardware and software across sites, minimizing operational variability.ConclusionWe identified factors that aid international implementation and operation of SMS-CASI for real-time adherence monitoring. The challenges and solutions we present can aid other researchers to develop and manage an international multilingual SMS-based adherence reminder and CASI system