A recent study from UCSF Health demonstrates that a multi-faceted outreach strategy can greatly enhance follow-up care for patients who are often difficult to reach after hospital discharge. The research highlights the importance of integrating various communication methods—including texts, automated messages, and live phone calls—to ensure that patients continue their treatment plans effectively.
After being discharged, many patients require ongoing care that involves medications, tests, and access to community-based services. However, hospitals frequently encounter challenges in maintaining contact with these individuals, which complicates their recovery process. The new findings underscore the critical need for effective communication in the post-discharge phase.
Innovative Approaches to Patient Support
At UCSF Health, a collaborative effort among nursing, social work, and pharmacy departments aims to provide comprehensive support for patients transitioning from hospital to home. For example, if a patient fails to fill a newly prescribed medication, their nurse can coordinate with a pharmacist to ensure prompt medication fulfillment and verify that the patient understands how to take their prescriptions correctly. Additionally, if social needs arise, such as food insecurity or housing issues, nurses can connect patients with social workers for assistance.
Lena Compton, RN, MS, a nurse coordinator for Care Transitions Outreach at UCSF Health, explained the approach: “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.”
Addressing Disparities in Patient Outreach
The study revealed significant disparities in how outreach methods reached patients based on race and ethnicity. Specifically, it was found that the standard automated phone calls were less effective for African American patients, successfully reaching only 70% of this demographic compared to 80% of patients overall. Meg Wheeler, RN, MS, manager of Care Transitions Programs, noted, “A significant disparity was revealed when we evaluated how our program reached patients based on race and ethnicity. We realized that we weren’t supporting certain populations effectively, and that meant they weren’t getting the help they needed.”
In response to these findings, the team adopted an integrated approach that utilized automated SMS text messages for all patients, complemented by live phone calls for those who could not be reached via text. This adjustment proved beneficial, as the engagement rate for African American patients rose to 76.4%. Overall, the reach rate for all patients improved from 80.2% to 83.7%.
The results of this pivotal study were published in the November 2025 edition of the Journal of General Internal Medicine. The article, titled “Closing the Equity Gap in Hospital-to-Home Care Transitions with Automated Post-Discharge Calls, Text Messages, and Focused Nursing Outreach,” emphasizes the importance of tailored outreach methods in improving post-discharge care.
By implementing these innovative strategies, UCSF Health is taking important steps toward ensuring that all patients receive the necessary support for their recovery, ultimately improving health outcomes for diverse populations.
