Multicomponent Operational Strategies to Support Follow-up Attendance in Child and Adolescent Psychiatry: A Longitudinal Evaluation

BACKGROUND: Missed follow-up appointments disrupt continuity of care and leave scarce outpatient psychiatric capacity underutilized. OBJECTIVE: To evaluate longitudinal changes in follow-up missed appointment rates (MAR) associated with operational strategies implemented in a child and adolescent psychiatry outpatient clinic. METHODS: We conducted a retrospective observational study using monthly data from July 2018 through December 2022. The intervention included telehealth expansion, implementation of the attendance engagement framework (AEF), and communication enhancements. Segmented interrupted time-series regression evaluated monthly follow-up MAR while accounting for time, the COVID-19 period, telehealth utilization, and AEF level and slope changes. An exploratory linear trend analysis evaluated phone abandoned call rates. RESULTS: The analysis included 54 months and 53,507 scheduled follow-up appointments. Monthly MAR declined from 12.0% in July 2018 to 6.0% in December 2022. Telehealth visits had lower MAR than in-person visits (5.6% vs. 11.1%, p < .001). The monthly slope decreased after March 2020 relative to the preceding trend (B = -0.005, 95% confidence interval [CI], -0.006 to -0.003; p < .001). Greater telehealth utilization was associated with lower monthly MAR (B = -0.112, 95% CI, -0.155 to -0.069; p < .001), corresponding to an estimated 1.1 percentage point lower MAR for each 10 percentage point increase in telehealth utilization. AEF implementation was not associated with a significant immediate level change (B = -0.020, 95% CI, -0.044 to 0.003; p = .091). The post-AEF slope changed significantly (B = 0.003, 95% CI, 0.001-0.005; p = .003), indicating that rates continued to decline, although more slowly. Phone abandoned call rates decreased from 50% to 2%. CONCLUSION: The multicomponent intervention was associated with sustained improvement in follow-up attendance. Flexible hybrid care, supportive attendance engagement, and reliable communication systems may help clinics use limited capacity more efficiently. Future evaluations should examine patient-level outcomes and equity.