Process improvement for behavioral health

Help Eliminate Barriers to Treatment


Clients are unable to overcome barriers to treatment on their own, even when willing, and drop out of treatment.


Help clients anticipate and solve the logistical problems involved with starting and staying in treatment. Such barriers may include transportation, childcare, ability to pay, translation needs, other appointments, the criminal justice system, and work schedules.

Featured Stories

Sinnissippi Centers in Dixon, Illinois reduced the no-show rate to the first appointment from 58 percent to 14 percent by using a conversational approach based on the spirit of Motivational Interviewing during the first call. They asked clients, “Do you see anything that may prevent you from making your appointment?” and “Do you have reliable transportation?”  They found that although they were prepared to offer and pay for a cab ride, that most clients did not need further help. They just needed to think through the logistics in advance.

The Center for Human Services in Seattle, Washington decreased no-show rates from 80 percent to 65 percent and increased admissions by 87 percent by performing assessments at the Community Service Office (the referrer) one day a week. For more information, see the CHS website.

Axis 1 in Barnwell, South Carolina worked with their local Medicaid transportation vendor to change their scheduling policies to make them more customer-friendly. They also worked with the county to find ways to pay for vehicles that the staff used to transport clients. They now have two vehicles to transport patients to and from treatment. This arrangement also allows the Axis 1 staff to spend more time with their clients. For more information, see Axis Change Bulletin.

Lessons Learned

  • Regular conversations about barriers to continuing in treatment may help clients solve problems and continue when personal or family issues arise.
  • If you decide to implement this promising practice both prior to admission as well as after admission, treat it as two separate aims and therefore two separate Change Projects, each with its own PDSA Cycles. This approach will make it easier and more manageable to introduce the change using small scale, rapid-cycles. It will also allow you to focus your improvement efforts and adapt the change so that it can be tailored to clients’ needs at that particular stage in the treatment process.

Tracking Measures

Cycle Measure

No-show rate for assessment appointments or treatment sessions.

Data Collection Form

No Show Tracking Spreadsheet



  • 1. Depending on the aim you’re focusing on, collect baseline data for the noshow rate to assessment appointments or to treatment sessions.
  • 2. Select one receptionist or counselor to test this change.
  • 3. Create a script for the staff member to use when asking clients about possible logistical barriers, including:
    • Transportation
    • Childcare
    • Scheduling issues


  • 4. Have the staff member discuss the logistical barriers to treatment with the next 40 clients or for all of their clients for the next two weeks, whichever happens first.
  • 5. Calculate the no-show rate at the assessment appointment or treatment sessions.


  • 6. Check the fidelity of the change. Was the change implemented as planned?
  • 7. Evaluate the change:
    • Did the no-show rate for the first appointment or for treatment sessions decrease for clients who discussed barriers?
    • Were clients able to solve their own logistical issues?
    • Is there a need for the agency to arrange for or offer these services?
    • What is the most effective way to ask questions about barriers to treatment?


  • 8. Adjust the questions that you are asking or the services that you are providing to eliminate barriers and re-test this promising practice for an additional two weeks.

Repeat this series of steps until all of your clients are asked about barriers to attending the first appointment and you are providing whatever services are feasible to eliminate the logistical barriers to treatment. Explore ways of asking clients about barriers on a regular basis, during treatment.

More Stories

Transportation Barriers

Spectrum Health Systems in Worcester, Massachusetts reduced no-shows from 48 percent to zero and increased revenue by $256 per week ($13,312 per year) for individual client sessions (billed at $64 each) by scheduling a clinician to provide on-site services for 8 hours per week in two parole-populated recovery programs. This eliminated scheduling and transportation issues. For more information, see Spectrum Health Systems.

CAB Health and Recovery in Peabody, Massachusetts began offering rides to clients entering detoxification.

Acadia Hospital in Bangor, Maine started asking not only if patients could come in the next day, but if they were able to get to the clinic. They then tried to help the clients figure out how they would get to the clinic, including using state-funded transportation from Medicaid.

TERROS, Inc. in Phoenix, Arizona makes house calls to help their clients complete paperwork.

ACTS in Tampa, Florida connected clients to Alcoholics Anonymous and Narcotics Anonymous, both of which provide free transportation to the agency.

Financial Barriers

Mid-Columbia Center for Living in Hood River, Oregon increased continuation rates from 70 percent to 80.1 percent by implementing a “Stay and Pay Later” card that allowed clients to delay payment for one week for up to four treatment sessions in a six-month period. Since financial barriers continue to be the single biggest reason that their clients delay entering treatment, they are still working to find ways to balance the needs of their clients with their needs as a business.

BestCare Treatment Services in Redmond, Oregon decreased the no-show rate for the initial intake appointment from approximately 40 percent to 25 percent in two different offices by waiving the fee for the initial intake appointment after learning that clients were not signing up for intake on the night of the orientation due to lack of money. The number of clients who scheduled intake appointments during orientation increased by 30 percent in the Bend office and by 18 percent in the Redmond office. BestCare forecasted an additional 60 percent in revenue in the outpatient program from clients who come for a free initial intake appointment and continue in treatment. For further information, the BestCare Change Bulletin.

Childcare Barriers

PROTOTYPES in Pomona, California offered an outpatient parent-child group that encouraged women and men without childcare to show up for treatment.

Translation Barriers

Asian Counseling and Referral Service in Seattle, Washington hire staff members who speak multiple languages and also arrange for translators to attend treatment sessions.