Nurse-led telephone outreach to assess patients' needs after hospital discharge can be effective in reducing unplanned readmissions in some settings, but these calls have limitations and are an operational burden. Researchers designed and implemented a 30-day postdischarge intervention that used automated texting to supplement the standard of care.

The intervention was implemented in a single primary care practice. Changes in postdischarge use of acute care resources in this practice were compared with those in a control practice serving a similar patient population.

Adults who were discharged after an acute care hospitalization and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible, and 430 patients were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. Patients in the intervention practice received automated check-in text messages on a tapering schedule for 30 days. Responses indicating that help was needed were routed back to the practice, where they were scheduled for a follow-up telephone call.

The 30-day rate of use of acute care resources in the control practice increased from 15.2% before the intervention to 19.8% afterward. In contrast, the rate in the intervention practice decreased from 20.3% to 16.5%. After implementation of the intervention, the odds of 30-day use of acute care resources were 41% lower in the intervention practice than in the control practice; the odds of readmission within 30 days were 55% lower.

The program was highly acceptable to patients, most of whom responded to messages and gave it high satisfaction ratings.

The authors note, however, that the study was conducted at a single site and patients weren't randomized. In addition, the study was conducted during the COVID-19 pandemic, when patients became more accustomed to remote outreach and virtual care, which may have enhanced uptake of the intervention.