How can a healthcare provider achieve patient-centered care for a diabetic and hypertensive adult patient with a history of missed appointments and well-controlled conditions, with an HbA1c (Hemoglobin A1c) level indicating adequate glucose control?

Achieving Patient-Centeredness for a Diabetic Patient with Missed Appointments

For this patient with well-controlled diabetes (HbA1c 7.2%) and hypertension but a history of missed appointments, patient-centered care requires addressing the underlying barriers to appointment adherence through structured outreach, flexible scheduling, and shared decision-making about visit frequency rather than simply scheduling more appointments. 1

Understanding the Core Problem

The pattern of missed appointments despite adequate glycemic control (HbA1c 7.2%) suggests that traditional appointment-based care may not align with this patient's needs, preferences, or circumstances. 1 Research demonstrates that patients who miss >30% of appointments have 0.7-0.8 points higher HbA1c on average, yet this patient maintains reasonable control, indicating some level of self-management capability. 2

Key insight: Missing appointments is not simply "non-compliance"—it represents a mismatch between the healthcare delivery model and patient circumstances. 1

Immediate Patient-Centered Interventions

1. Conduct a Barriers Assessment

Explore specific reasons for missed appointments through open-ended conversation: 1

• Transportation challenges: Does the patient have reliable transportation to clinic visits? 1
• Work schedule conflicts: Are appointment times incompatible with employment obligations? 1
• Financial barriers: Are copays or lost wages from time off work prohibitive? 1
• Health literacy concerns: Does the patient understand the purpose and value of regular visits? 1
• Competing priorities: Are there family caregiving responsibilities or other health conditions taking precedence? 1

2. Implement Proactive Outreach

Establish a pre-visit phone call system to optimize engagement: 3

• Contact the patient 3-5 days before scheduled appointments to confirm attendance, address barriers, and review visit goals. 3
• Use these calls to assess current symptoms, medication adherence, and self-monitoring practices. 3
• Preliminary data show that centralized care management teams making pre-visit calls improve appointment attendance and completion of recommended preventive services. 3

3. Redesign Visit Frequency Based on Patient Preference

Negotiate a mutually acceptable follow-up schedule: 4

• For patients with HbA1c 7-8% and stable control, the American Diabetes Association supports HbA1c monitoring every 6 months rather than quarterly. 4
• This patient's HbA1c of 7.2% falls within acceptable control, making less frequent visits clinically appropriate. 4
• Offer alternatives such as telehealth visits, group medical appointments, or nurse-led phone management to reduce visit burden. 5

4. Establish Clear Communication About Goals

Engage in shared decision-making about glycemic targets: 4

• The American College of Physicians supports HbA1c targets of 7-8% for most adults with type 2 diabetes, which this patient is achieving. 4
• Explicitly acknowledge the patient's success in maintaining control despite missed appointments. 4
• Discuss whether the current HbA1c target aligns with the patient's values, life circumstances, and willingness to intensify therapy. 4

Addressing the Specific Context

Why Traditional Appointment Models May Fail

Emergency department encounters provide "teachable moments" for medication compliance and lifestyle modification counseling, suggesting that opportunistic engagement may be more effective than scheduled visits for some patients. 4 Similarly, this patient's ability to maintain glycemic control despite missed appointments indicates that rigid appointment schedules may not be necessary for adequate disease management. 2

Alternative Care Delivery Models

Consider group medical clinics if available: 5

• Group medical clinics with 7-8 patients, led by a care team including a physician, pharmacist, and diabetes educator, have demonstrated effectiveness for patients with both diabetes and hypertension. 5
• These sessions include structured group interactions and medication adjustments, potentially offering more value per visit and reducing the total number of required appointments. 5

Implement nurse-led telephone case management: 6

• While one study showed mixed results in community practices, telephone-based behavioral management can maintain contact without requiring in-person visits. 6
• Calls every 2 months (6 per year) may be more feasible than quarterly clinic visits for patients with scheduling barriers. 6

Critical Pitfalls to Avoid

Do not label this patient as "non-compliant" or "difficult": 1

• This judgmental framing undermines the therapeutic relationship and ignores systemic barriers to care access. 1
• Patient-centered care requires understanding that missed appointments often reflect healthcare system failures rather than patient failures. 1

Do not aggressively intensify glycemic targets: 4

• The patient's HbA1c of 7.2% represents adequate control; targeting <7% would increase treatment burden without proven benefit for microvascular or macrovascular outcomes. 4
• More stringent targets increase hypoglycemia risk and medication burden, potentially worsening appointment adherence. 4

Do not simply schedule more frequent appointments: 1

• Adding appointments without addressing underlying barriers will likely result in more missed visits. 1
• Focus on optimizing the value and convenience of each encounter rather than increasing visit frequency. 3

Practical Implementation Strategy

Immediate Actions (This Visit)

• Acknowledge the patient's success in maintaining glycemic control. 4
• Ask open-ended questions: "What makes it difficult for you to come to appointments?" 1
• Negotiate next appointment timing based on patient preference (offer 3-6 month options). 4
• Provide direct contact information for the care team to address urgent concerns between visits. 3

Short-Term Follow-Up (1-3 Months)

• Implement pre-visit reminder calls with barrier assessment. 3
• Consider telehealth or phone visits as alternatives to in-person appointments. 6
• Evaluate whether group medical clinics are available and acceptable to the patient. 5

Long-Term Monitoring (6-12 Months)

• Reassess HbA1c every 6 months given stable control. 4
• Monitor appointment attendance patterns and adjust outreach strategies accordingly. 2
• Maintain flexibility in visit scheduling based on evolving patient circumstances. 1

Documentation and Care Coordination

Ensure discharge planning principles apply to outpatient transitions: 4

• Document the agreed-upon follow-up plan in the medical record with specific dates and modalities (in-person, phone, telehealth). 4
• Communicate the patient's barriers and preferences to all care team members. 4
• Schedule the next appointment before the patient leaves, with patient agreement on timing. 4

The essence of patient-centered care for this individual is recognizing that maintaining HbA1c 7.2% despite missed appointments demonstrates effective self-management, and the provider's role is to support rather than override the patient's existing strategies. 4, 1