Leveraging Technology to Support Safer Transitions of Care

Getting discharged from the hospital can sometimes feel like getting pushed off a cliff. Patients transition from 24-hour medical supervision, where all needs are cared for, to where “patients must suddenly adjust to little or no clinical support at home.” 1 This dynamic can be challenging and leaves patients feeling vulnerable to relapse and readmission and medical doctors feeling disconnected from the patients’ recovery.

Eric Bressman, MD, MSHP and Anna Morgan, MD, MSc, University of Pennsylvania, School of Medicine, Department of Medicine, spoke to the Patient Access Collaborative about new approaches to patient care at UPenn, which included employing a 2021 pilot study of the “TCM + 30-Day Post Discharge Program,” designed to test how connected care technology could support patients with the transition from the hospital and help to taper the post-discharge cliff drop.

Bressman relayed, “Connected Care” is a “more proactive, incremental approach to healthcare focused on leveraging the tools of technology to engage patients remotely.” It “bucks” the more traditional, visit-based model, which is episodic, to offer a more continuous, ongoing patient engagement experience. “Connected Care” encompasses three primary pillars of support:

• (a.) virtual care (telemedicine visits)
• (b.) digital and mobile health (emails, calls, texts), and
• (c.) remote patient monitoring, which also utilizes (a.) and (b.) to gather physiological data from patients.

Bressman stated, “with this newer technology, we can leverage all the resources of the healthcare system, hospital, and clinic to mitigate the cliff drop effect through supervision; Patients going from 24/7 hospital care to meeting patients where they are and in their homes.”

Morgan explained during COVID, there was “a huge uptick in text messaging, which prompted UPenn to examine messaging in the hospital space for use after hospital discharge.” Using a patient-centered model, UPenn approached the influx of messaging and launched the “TCM + 30 Day Post Discharge Program” from January-August of 2021, where patients received automated check-in text messages over a 30-day period from their primary care practice. Text messages were sent to patients on a tapering schedule, from 3 times per week to one time per week. Patients were prompted with simple questions, and their responses were used to gather information before a follow-up phone call from a nurse.

The messages in the program were, by design, fairly simple. They would ask: “Is there anything we can help you with today?” And the patient would answer (Y) Yes or (N) No. If they said no, they wouldn’t hear from the program again until the next check-in, though they would be invited to proactively text in at any time. If they said yes, the patient received options to respond:

• (a.) I don’t feel well, or
• (b.) I need help with medicines, etc.,

The goal was to improve patient outcomes by proactively identifying and addressing any ongoing needs and symptoms. Morgan noted, “using an automation intervention increased the number of touch points with patients, identified needs earlier, increased engagement, and decreased barriers to patients.”

The team was cognizant of not wanting to burden patients and staff with accumulating messages and outreach, particularly in a landscape where these types of programs have grown. Thankfully, the program was overwhelmingly accepted by both groups. In a recent JAMA Network Open report, the team reported encouraging clinical outcomes. Of the 430 patients enrolled, 360 (83%) replied to the initial messages. Nurses made only 1.4 additional calls per day. 2 Compared to the control group (traditional care), the automated messaging group was associated with lower odds of acute care during the 30-day after discharge and a 55% decrease in the likelihood of readmission.

The results suggest that a patient-centered, automated texting program may serve as a model to support safer care transitions after hospital discharge. Bressman and Morgan (2022) noted, “the findings are encouraging and indicate that in a fragmented landscape, relatively simple applications of technology can help patients feel more connected to their care team and help practices provide additional support in a scalable way.” 3

Bressman and Morgan remarked on their current work: the texting pilots were expanded to include a large swath of UPenn’s primary care practices. The uptick of activity revealed a challenge: scaling up meant taking into consideration a wide range of workflows and needs from different clinics. Their sentiments echo the opportunities that access leaders at other academic health systems experience. Spreading technology does not present challenges for the tool itself; however, scaling the workflow that leverages the technology to improve performance may require greater care.

1 Bressman E, Morgan A, Automated Texting Shows Promise to Reduce Hospital Readmissions. Frequent Text Check-Ins After Hospitalization Helped Patients Access Follow-Up Care. Penn LDI. 2022 Oct 26.

2 Bressman E, Long J, Honig K, Zee J, Mcglaughlin N, Jointer C, Asch D, Burke R, Morgan A. Evaluation of an Automated Text Message-Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge. JAMA Network Open. 2022 Oct 3;5(10):e22388293. Doi:10.1001/jamanetworkopen.2022.38293.

3 Bressman et al. 2022; 10(26).