Opportunity

Strategies to manage patient care after discharge are critical for bridging care gaps between hospital and home, identifying needs early, and preventing the unnecessary use of acute care resources.

Many health systems deploy primary care nurses to conduct standard transitional care management phone (TCM) calls to manage the transition. Unfortunately, these calls tend to be time intensive, restricted in scope, and limited in terms of the number of connection points and timing over the course of recovery.

Intervention

Researchers at the University of Pennsylvania leveraged Way to Health to test whether automated text messaging could support post-discharge care management and reduce emergency department (ED) visits and hospital readmissions.

During the initial pilot of Mobile Outreach to Reduce Emergencies (MORE-PC), patients in the control group received a TCM call within two days of discharge. The intervention group received a TCM call plus check-in text messages from their primary care practice for 30 days after discharge, delivered according to a tapering schedule. If patients texted back expressing a need, responses were escalated to the practice for follow-up.

Impact

Compared to the control group, patients receiving the texting intervention had 55 percent lower odds of readmission and 41 percent lower odds of acute care resource use overall. No significant difference was found for ED visits alone or mortality.

The texting program received a net promoter score of 67, and many of the patients in the intervention were responsive: Nearly 83 percent responded to an introductory text message. Among the escalation incidents, more than 86 percent came in response to an automated check-in. The number of escalations – an average of 1.4 per day – was considered manageable by the care team.

A randomized controlled trial testing the MORE-PC intervention has also been completed. Results will be posted here once they become available.