Closing the Equity Gap in Hospital-to-Home Care Transitions with Automated Post-Discharge Calls, Text Messages, and Tailored Outreach

Learning outcome: We augmented an automated post-discharge calls program with tailored outreach strategies to improve rates and close an equity gap in post-discharge communication. This approach has the potential to improve post-hospital recovery among at-risk populations.

Post-discharge calls are recommended as part of comprehensive care transitions programs, because they reduce patient anxiety and improve clinical outcomes. However, calls are time and resource intensive and may be limited in reaching at-risk individuals. Studies have shown that adding a text message option to post-discharge programs can increase post-discharge follow-up in surgical and established primary care patients, but this approach has not been tested in other at-risk populations.

In 2013, we implemented a hospital-wide automated, multilingual post-discharge phone call program as part of the care transitions outreach program (CTOP). Patient-reported post-discharge concerns are first identified via automated telephonic outreach. For certain "at-risk" patients who fail to answer the automated call—age >85 years, discharged home with services, or limited English proficiency—a nurse reviews the chart and calls the patient if they have not already been contacted by another clinician. For all patients who answer the automated or nurse call and identify a concern, a nurse speaks with the patient to provide symptom triage, teaching, care coordination, and referrals to social work, pharmacy, and/or patient relations, as indicated.

CTOP now calls 27,000 patients annually (nearly all hospital discharges), with a 77% reach rate with the notable exception of black and/or African-American (B/AA) patients, who had a markedly lower 65% reach rate. To improve our overall reach rates and to address the identified inequity, we developed a tailored outreach escalation approach to enhance reach rates. First, patients who failed to answer the automated call received a follow-up text message with the same information as the automated call and translated into the same languages. Then, a CTOP nurse reviewed the chart for B/AA patients who did not respond to the automated call nor the text, and placed a personal call if no other clinician contact documented.

Adding text messages increased the overall reach rate from 77% to 84%. For B/AA patients, adding text messages increased the reach rate from 65% to 71%; adding a personal call (to 79 patients) further increased the reach from 71% to 77%. Because the text option increased the overall reach rate, it reduced the number of patients requiring a personal call. This helped improve efficiency, as nurses were able to complete calls to this limited number of patients within the scope of their existing roles and without requiring additional hours or CTOP personnel.