Process improvement for behavioral health

Collaborate with Referrers to Motivate Clients


Referrers do not use their influence to create natural consequences if the client doesn’t show.


Collaborate with referrers who have the authority to follow up when clients miss an assessment appointment or treatment sessions.

Featured Stories

Brandywine Counseling in Wilmington, Delaware, increased continuation rates from 45 percent to 89 percent in three months by informing referrers of client no-shows and seeking their help in re-engaging clients. Re-engagement rates for probation outpatients increased from 41 percent to 53 percent when probation officers  received a letter. Re-engagement rates for clients referred by family services increased from 14 percent to 43 percent in the first month. Brandywine asked probation officers if they would collaborate without penalizing clients when they dropped out of treatment. Case managers also started making follow-up phone calls to outpatients who did not show up for their first step group.

Kentucky River Community Care (KRCC) in Jackson, Kentucky, increased the percentage of clients who completed the transition to the next level of care after  hospital-based detoxification services from 30-38 percent to 56 percent. KRCC worked with referral sources to make sure that clients who were referred actually contacted the agency and appeared for the first appointment. KRCC also notified referral sources by phone or letter if a client did not show.

Lessons Learned

  • Acknowledge all referrals.
  • Have referrers notify the provider when they make a referral.
  • Notify referrers if a client missed the first appointment or treatment sessions.
  • Keep referrers informed about their clients’ progress in treatment.
  • Provide progress reports to referral sources about clients in a format for easy tracking and reporting easier. This may help reduce the workload for probation officers and child protective services workers.
  • Work with referral sources to offer less attractive alternatives to treatment, such as:
    • Loss of employment (employer)
    • Incarceration (drug court, probation officer)
    • Loss of child custody (child protective services)
  • Let clients know that the referrer will be informed about their attendance.
  • Ask the referrer to help eliminate barriers by bringing the client to the agency for their first appointment.
  • Have someone from your agency attend drug court to schedule clients immediately.
  • Use Ten Steps to Targeted Admissions

Tracking Measures

Cycle Measure

  • No-show rate to assessment appointment or treatment sessions
  • Reschedule rate for clients who do not show for a scheduled appointment
  • Percentage of referred clients who were admitted

Data Collection Forms



1. Select one referrer to work with and include a representative from the referrer on the Change Team.

2. Work with the referrer to plan how they will let your agency know that they have made a referral and how you will let them know if they client did not contact your agency or did not show for appointments.

3. Depending on the aim that you’ve selected, collect baseline data for:

  • No-show rate
  • Reschedule rate for clients who do not show for a scheduled appointment
  • Percentage of referred clients admitted


4. Communicate with the referrer to let them know which clients did not show for their appointments for the next two weeks.

5. Track these clients and calculate their no-show rate to determine whether they show for a rescheduled appointment.


6. Check the fidelity of the change. Was the change implemented as planned?

7. Evaluate the change:

    • Did the referrer follow up with the client?
    • Depending on the aim you’ve selected: did the no-show rate decrease or did clients reschedule appointments?


8. Adjust the way that you communicate with the referrer and re-test this promising practice for an additional two weeks.

Repeat this series of steps until you have forged collaborative working relationships with your most frequent referral sources or referral sources with whom you want to develop stronger relationships.

More Stories

St. Christopher’s Inn in Garrison, New York, cultivated relationships with unions and union employee assistance programs (EAPs). The person making the referral actually brought the men to the treatment program. For more information, see the case study, St Christophers Inn EAP.

Daybreak Youth Services in Spokane, Washington, set minimum standards around contact with referrers: the intake counselor calls the referrer on the day of admission to inform them of the admission; the primary counselor makes contact within 24 hours to exchange information and set up the protocol for treatment updates; and, the primary counselor always calls within the last two weeks of treatment to set up aftercare sessions, report on progress, and make recommendations.

Connecticut Renaissance, Inc. in Bridgeport, Connecticut, worked with referral sources to follow up when clients missed appointments. If the treatment agency had no contact with a client for three weeks, they met with the referrer to discuss the client’s treatment needs and referral mandates.