Understanding the impact and causes of ‘failure to attend’ on continuity of care for patients with chronic conditions

Abstract

Aim To understand the impact and causes of ‘Failure to Attend’ (FTA) labelling, of patients with chronic conditions. Background Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended. Method The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation. Results Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient’s capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap. Conclusion The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase ‘Failure to Attend’ has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase “appointment did not proceed” to replace FTA. Implications for Nursing management This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term ‘appointment did not proceed.’

Health (il)literacy: Structural vulnerability in the nurse navigator service

“…Like the above study, health literacy in the nurse navigator service discursively constitutes individuals as rational, choice making citizens. However, when the person is not able to achieve literacy, this position may also instil a sense of deficiency and even blame on individuals (often translated as label such as non‐compliant), rather than on structural and systemic issues which hinder knowledge and participation (Byrne et al, 2021; Singh & Sherchan, 2019).…”

“…Yet, it is well documented that service budgets leave nurses time poor, meaning that some care is inevitably lost, as they make decisions about what care is done and what is left undone (Jones et al, 2015). Person‐centred care is often at odds with the neoliberal agenda of health service management (Byrne et al, 2021). Conformity spills over to how other actors behave within hospitals; patients, their families, and the community all conform to institutional rules of behaviour (Burchell et al, 1991).…”

“…This is supported by the care trajectory of service, which states that in a period of 12 months, the individual is discharged with ‘good health literacy’ and can manage their own healthcare needs (Queensland Health, 2018, p. 7). Yet, data from the evaluation show that health literacy is not a measure controlled by the nurse navigator; it is a patient‐unique situation, based upon their own capacity to manage, severity of illness, family and social determinants, as well as a systems issue (Byrne et al, 2021).…”

“…The population groups identified as accessing the most healthcare resources are those with multimorbidity, First Nations people, and those over the age of 65 years (AIHW, 2018). This demographic also has more frequent presentations to emergency, subsequent admissions, higher rates of polypharmacy and, due to the multiple specialties involved in their care, frequently fail to attend appointments (Byrne et al, 2021; Harvey et al, 2020; Sheridan et al, 2012; Wehling, 2009). Accordingly, models of care that include coordination, integration and navigation have emerged to better serve these vulnerable populations, with the purpose of improving self‐efficacy and reducing hospital presentations and admissions.…”

Achieving continuity of care in general practice: the impact of patient enrolment on health outcomes

“…In its stead, Medicare‐funded Chronic disease GP Management Plans and Team Care Arrangements were introduced to coordinate multidisciplinary care, care coordinators to improve consistency of care, and a patient‐controlled electronic health record to improve informational continuity 7 . However, evidence that these measures achieve comparable continuity or outcomes is scarce, and evidence of errors and poor outcomes attributable to inadequate continuity of care continue to be reported 8,9 …”