Not Seen Not Found

Service: Risk Management
Subject: Care
Setting: Communication

Not seen not found (NSNF) incidents or visits refer to circumstances where the home care provider, case manager or agency is unable to deliver a scheduled visit as client is either not at home, and/or does not respond to  phone calls or electronic communication. Balancing client autonomy and risk of harm (if the service or care is not provided), is especially challenging for clients without access to a phone, in temporary housing (e.g., shelter) and/or with mental health clients with underlying medical issues. Consistency and clarity for the identification of such incidents and timely reporting are critical to reducing the likelihood of the client’s condition deteriorating. Inconsistent reporting and management of NSNF events have resulted in client deaths and subsequent investigations by the Coroner.

Common Claim Themes

System issues

  • Lack of and complicated NSNF policies (e.g., process embedded in one or more protocols).
  • Variations between health authorities, case managers, coordinators and home care providers and agencies regarding:
    • Identification, management and expectations regarding NSNF;
    • Definitions and compensation for a NSNF visit, cancelled visit and missed visit;
    • Each party’s roles and responsibilities associated with a NSNF visit.
  • Compliance with NSNF reporting requirements negatively impacting compensation (in some cases, the home care provider or agency is not paid for the visit).
  • Inadequate home care provider, agency worker and case manager staff education regarding NSNF reporting expectations.

Knowledge and judgement

  • Poor compliance with NSNF and missed visits protocols contributing to delayed communication and initiation of searches in particular after hours and on weekends. 
  • Failure to identify and communicate NSNF risk factors to the coordinating agency or case manager including (but not limited to):
    • Leaving the client’s home knowing the client is likely inside and/or may need assistance (car still in driveway, mail or newspapers piling up, snow covered driveway or car, lawn not mowed, etc.);
    • Failure to report the client’s concerns and disagreements regarding the nature and frequency of visits.
  • Failure to investigate the reasons for clients with a history of NSNF visits.
  • Reduced vigilance with clients known to cancel appointments.
  • Failure to notify family or contacts provided by the client as part of the search protocol. 

Mitigation Strategies

Reliable Care Processes

  • Implement strategies to ensure individualized assessments are conducted to identify clients at risk of not responding (e.g., clients with dementia, fall, mental health issues, history of missing or not responding to scheduled visits) or at risk for harm from missing or not responding to visits or services. 
  • Adopt a standardized protocol and/or algorithm to address clients not responding to scheduled visits or services that includes (but is not limited to):
    • The use of standardized terminology (e.g., NSNF versus missed or cancelled visit) for communicating and documenting a NSNF visit;
    • The need to specify the level of urgency when reporting a NSNF visit based on client risk assessment;
    • The specific steps to be taken (escalation protocol) by care providers and case managers and coordinators (including patient in transitions in care) in cases where the client cannot be located, does not respond to follow up calls or electronic communication for confirmation of scheduled visit,  and when a family member is unable to reach or contact the client;
    • Communication and reporting expectations between case manager, coordinator, home care providers, agencies, and family or personal contacts including after hours, weekends and holidays (e.g., how many attempts to reach the client, the type of attempt, escalation process), and if the visit is a first home visit or ongoing schedule;
    • The need for home care providers and agencies to communicate to their office/superior and case manager or coordinator regarding any changes, including changes requested by the client; 
    • The need to conduct a brief environmental scan before leaving a NSNF client’s home for triggers the client may be at home but unable to respond (e.g., mail piling up, car in driveway and no snow removal).
  • Implement strategies to support the timely communication of any changes to the frequency of visits between the home care providers/agencies and case manager/coordinators.
  • Develop a calendar of scheduled visits, with appropriate reminders and notifications, for each client with a copy provided to the client, the client’s care provider or family (as appropriate).

Client and Family-Centred Care

  • Implement formal strategies to ensure the client intake process includes a documented and agreed-to emergency response or escalation plan for when the client does not respond to a scheduled visit or service, for example:
    • With consent, consider involving the client’s care provider or family in the emergency response development. Consider strategies based on individual client circumstances (e.g.,  for an individual living alone, the option of obtaining a spare key (such as through a lock box, or neighbor) to the client’s home and the specific circumstances under which the key may be used;
    • Ensuring the plan is incorporated into the client’s regular care plan review and is readily available for the involved case managers, coordinators and team members.
  • Ensure contact information is up-to-date for the case manager, coordinator, and home care provider/agency including for after-hours contact information.

Contracts

  • Ensure home care provider/agency services contract includes a clear definition and wording regarding the expectations for identifying, responding to, reporting and compensation for NSNF, cancelled, and missed visits.

Monitoring and Measurement

  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and interdisciplinary adherence to NSNF, missed and cancelled visit guidelines, protocols and algorithms, including:
    • Adoption of formal quality measures and indicators;
    • Sharing of learnings from NSNF, missed and cancelled visit incidents (e.g., learnings from chart audits, trigger tools, incident reports, team debriefs, critical incident, adverse event,  quality of care and quality improvement committee reviews, medical legal claims, coroner reports and related recommendations).

Resources

  • HIROC claims files.
  • Accreditation Canada. (2016). Required organizational practices handbook 2016: Home safety risk assessment: 67.
  • Alberta Health Services (2016). Missed visit by home care service provider. [policy documents].
  • Canadian Patient Safety Institute. (2009). State of the knowledge regarding safety in homecare in Canada: An environmental scan.
  • Community Legal Education Ontario (CLEO). (2015). Homecare bill of rights.
  • Government of Manitoba. (2015). Your guide to home care services in Manitoba.