A recent study from UCSF Health highlights improved follow-up care for hard-to-reach patients through a combination of outreach methods, including texts, automated messages, and live phone calls. As patients transition from hospital to home care, an effective follow-up is crucial for ensuring adherence to treatment plans, which often include medication and community services. Many hospitals face challenges in maintaining contact with these individuals post-discharge, complicating their recovery process.
Collaboration for Comprehensive Care
At UCSF Health, a collaborative effort among nursing, social work, and pharmacy departments ensures that patients receive necessary support after leaving the hospital. If a nurse identifies that a patient has not filled a newly prescribed medication, they can coordinate with a pharmacist to verify that the medication is ready and that the patient understands how to use it safely. In cases where patients require additional assistance, such as food delivery or housing support, social workers are contacted to address these social needs.
Lena Compton, RN, and nursing coordinator for Care Transitions Outreach, emphasizes the importance of asking the right questions. “Patients are often overwhelmed after discharge and don’t realize what they’re missing until we ask,” she stated. This proactive approach helps ensure that patients are aware of their resources, understand their care instructions, and can access medications and follow-up appointments without barriers.
Addressing Disparities in Patient Outreach
The study, conducted by the Care Transitions Outreach nursing team, revealed a significant disparity in outreach effectiveness among different racial and ethnic groups. Automated phone calls reached only 70% of African American patients compared to 80% of the general patient population. Meg Wheeler, RN and manager of Care Transitions Programs, noted, “We realized that we weren’t supporting certain populations effectively, and that meant they weren’t getting the help they needed.”
To address this gap, the team implemented a more integrated outreach approach. They introduced automated SMS text messages for all patients, complemented by live phone calls for those who could not be reached by text. This strategy proved effective, with engagement among African American patients rising to 76.4%. Overall, outreach success improved, with the combined patient reach rate increasing from 80.2%% to 83.7%%.
The results of the study were published in the Journal of General Internal Medicine in November 2025, highlighting the importance of innovative outreach strategies in improving follow-up care and addressing healthcare disparities. The research underscores the necessity for hospitals to adapt their communication methods to better meet the needs of diverse patient populations.
The findings serve as a crucial reminder of the impact that effective communication can have on patient health outcomes, particularly for those facing barriers to care. By refining outreach methods and focusing on collaboration, healthcare providers can significantly enhance the recovery experience for patients transitioning from hospital to home care.
