Background: To support patients after hospital discharge, we developed and implemented a 30-day automated text-messaging intervention. The program was piloted in a single practice in Philadelphia, and was associated with a significant reduction in 30 day readmission and utilization of acute care resources. However, we wanted to understand the timing and nature of patient needs following discharge that were addressed through the intervention.
Methods: Escalations were defined as instances in which a patient would report they needed help via text, followed by a categorization of their needs. Each escalation was reviewed in the EHR to determine: (1) days from hospital discharge to initial escalation, (2) reason(s) for escalation, and (3) outcome(s) of escalation. The reasons and outcomes were then categorized according to the Ideal Transition of Care framework (see Table 1), which was modified to fit the patient needs data from our analysis. Escalations were often complex, and multiple needs may have been addressed; therefore escalations could be assigned to more than one category.
Results: The study data set included 199 unique escalations reflecting 235 categories. Escalations were most frequent 0-5 days after discharge (30.1%), with 77.0% of escalations occurring within the first 15 days after discharge (Table 2). The three most frequent categorizations were: Monitoring and Managing Symptoms After Discharge (26.8%); Outpatient Follow-Up (20.4%); and Medication Needs and Reconciliation (15.7%).
Conclusions: This analysis demonstrates that patients utilize the texting program appropriately, expressing similar needs as reported in comparable call-based programs. Three quarters of needs arose within the first two weeks of the 30 day program. The needs identified were relevant to primary care practice and generally fell within nursing scope of practice. This program can serve as a model for health systems looking to support safer transitions, and the findings of this analysis can inform future iterations of this approach.
