Combination of outreach methods can improve follow-up care for hard-to-reach patients

A combination of outreach methods – including texts, automated messages, and live phone calls – can significantly improve follow-up care for hard-to-reach patients after they have been discharged, according to a new nursing study from UCSF Health.

After patients are discharged from the hospital, they often require an ongoing treatment plan that involves medication, tests, and community-based services. Following these plans can improve the results of their treatment, but many hospitals struggle to reach patients after they're discharged, making it challenging to support their recovery.

The right questions guide the best care

At UCSF Health, the nursing, social work, and pharmacy departments collaborate to ensure patients can access medication and home health care, and have immediate support for social needs once they've left the hospital.

If a patient hasn't filled a newly prescribed medication, for instance, their nurse might tap a pharmacist, who can check that the patient's medication is filled promptly, confirm the patient's medication list is accurate, and ensure the patient understands how to take each prescription safely. The nurse may also contact a social worker to arrange for local food delivery or housing assistance if a patient needs help in those areas.

Patients are often overwhelmed after discharge and don't realize what they're missing until we ask the right questions. We ensure patients have the resources they need, understand their care instructions, and can access their medications and follow-up appointments. This is where gaps can occur, and our team steps in to make sure nothing falls through the cracks."

 Lena Compton, RN, MS, UCSF Health nurse coordinator for Care Transitions Outreach

Addressing the gap for each patient

The study, led by UCSF Health's Care Transitions Outreach nursing team, found that the standard automated phone call was far less effective in reaching African American patients than other patients, reaching only 70% of patients in that community versus 80% of patients overall.

"A significant disparity was revealed when we evaluated how our program reached patients based on race and ethnicity," said Meg Wheeler, RN, MS, manager of Care Transitions Programs. "We realized that we weren't supporting certain populations effectively, and that meant they weren't getting the help they needed."

The team switched to an integrated approach that used automated SMS text messages for all patients, paired with live phone calls for those who couldn't be reached by text. They measured improvement by how many patients responded to the outreach. The researchers found that adding text messages increased their engagement of African American patients to 76.4%. The new methods also improved outreach for other patients: the reach rate for all patients combined jumped from 80.2% to 83.7%.

Results were published in November in the Journal of General Internal Medicine.