A recent study from UCSF Health has identified a combination of outreach methods that can significantly enhance follow-up care for patients who are often hard to reach after hospital discharge. The research highlights the importance of integrating texts, automated messages, and live phone calls to ensure that discharged patients continue their necessary treatment plans, which may include medications, tests, and community-based services.
Upon discharge, many patients are left navigating complex aftercare protocols on their own. The study emphasizes that adhering to prescribed treatment can lead to better health outcomes, yet hospitals frequently struggle to maintain contact with patients once they leave the facility. This gap in communication can hinder recovery and complicate management of ongoing health issues.
Collaborative Care Approach
The nursing, social work, and pharmacy departments at UCSF Health work hand in hand to support patients post-discharge. For example, if a patient has not filled a newly prescribed medication, their nurse can consult with a pharmacist to ensure the prescription is filled in a timely manner. Additionally, if a patient requires help with social needs, such as food delivery or housing assistance, a social worker can be contacted to provide resources.
According to Lena Compton, RN, MS, and nurse coordinator for Care Transitions Outreach at UCSF Health, “Patients are often overwhelmed after discharge and don’t realize what they’re missing until we ask the right questions.” This proactive approach aims to ensure that patients have the necessary resources, understand their care instructions, and can access medications and follow-up appointments effectively.
Identifying Disparities in Care
The study, led by UCSF Health’s Care Transitions Outreach team, revealed significant disparities in how outreach methods affected different patient demographics. For instance, the standard automated phone calls were less effective for African American patients, who were reached only 70% of the time, compared to an overall reach of 80% for all patients.
“We realized that we weren’t supporting certain populations effectively, and that meant they weren’t getting the help they needed,” said Meg Wheeler, RN, MS, manager of Care Transitions Programs. This insight prompted the team to reassess their outreach strategies.
By implementing an integrated approach, the team introduced automated SMS text messages for all patients. This was paired with live phone calls for those who could not be reached via text. The study measured success by tracking patient responses to these outreach efforts. The results showed that engagement among African American patients increased to 76.4%. Overall, the reach rate for all patients improved from 80.2% to 83.7%.
The findings were published in the November 2025 edition of the Journal of General Internal Medicine. This research underscores the necessity for healthcare systems to adapt their communication strategies to address the unique needs of varied patient populations, ultimately aiming for equitable healthcare access.
For further details, see the study: Wheeler, M., et al. (2025). Closing the Equity Gap in Hospital-to-Home Care Transitions with Automated Post-Discharge Calls, Text Messages, and Focused Nursing Outreach. Journal of General Internal Medicine. doi: 10.1007/s11606-025-09720-2.
