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. The named the program Mobile Outreach to Reduce Emergencies (MORE-PC).

The team conducted a pilot study and subsequently a randomized controlled trial (RCT) to evaluate 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

The pilot showed promising results: 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.

In contrast, the randomized controlled trial found no difference in readmissions or ED visits between in the control group and those receiving the MORE-PC intervention. However, the program had relatively high engagement – 80 percent of participants answered at least one message – and the team identified at least one care need for 42 percent.

A further analysis of the pilot study identified themes among the needs of MORE-PC patients, which could help target key needs in future interventions. The most common needs escalated were related to symptoms, coordinating follow-up care, and medication issues.