Text Messaging Enhances Patient Follow-Up Care Post-Discharge

A recent study from UCSF Health has highlighted the effectiveness of various outreach methods, including text messages, automated calls, and live phone interactions, in improving follow-up care for patients after hospital discharge. Published in the Journal of General Internal Medicine, the research reveals that these combined approaches can significantly enhance the support provided to patients who are often difficult to reach.

After leaving the hospital, patients frequently require ongoing treatment plans involving medication, diagnostic tests, and community services. Adhering to these plans is crucial for effective recovery, yet many healthcare providers face challenges in reaching patients post-discharge, which can hinder recovery efforts.

Collaborative Approach to Patient Care

At UCSF Health, a multidisciplinary team comprising nursing, social work, and pharmacy professionals collaborates to ensure patients have access to necessary medications and home healthcare services. For instance, if a patient does not fill a new prescription, nurses can coordinate with pharmacists to ensure timely medication access and confirm that patients understand how to safely use their prescriptions. Additionally, social workers can assist with local food delivery or housing if needed.

“Patients are often overwhelmed after discharge and don’t realize what they’re missing until we ask the right questions,” said Lena Compton, RN, MS, nurse coordinator for Care Transitions Outreach at UCSF Health. “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.”

Addressing Disparities in Patient Outreach

The study identified significant disparities in outreach effectiveness among different racial and ethnic groups. Meg Wheeler, RN, MS, manager of Care Transitions Programs, noted that standard automated phone calls reached only 70% of African American patients, compared to 80% of patients overall. “A significant disparity was revealed when we evaluated how our program reached patients based on race and ethnicity,” Wheeler stated. “We realized that we weren’t supporting certain populations effectively, and that meant they weren’t getting the help they needed.”

In response, the team adopted an integrated strategy that combined automated SMS text messages with live phone calls for those who could not be reached via text. The results were promising; the outreach engagement rate for African American patients increased to 76.4%. Overall, the reach rate for all patients rose from 80.2% to 83.7% with the new outreach methods.

This study underscores the importance of personalized communication in healthcare, particularly for populations that may face barriers to accessing care. By leveraging technology and a team-based approach, UCSF Health aims to close the gap in hospital-to-home care transitions and ensure all patients receive the support they need to thrive post-discharge.

For further details, refer to the study by Margaret Wheeler et al, titled “Closing the Equity Gap in Hospital-to-Home Care Transitions with Automated Post-Discharge Calls, Text Messages, and Focused Nursing Outreach,” published in the Journal of General Internal Medicine in 2025. DOI: 10.1007/s11606-025-09720-2.