New Outreach Methods Boost Follow-Up Care for Patients Discharged from Hospital

A recent study from UCSF Health reveals that utilizing a combination of outreach methods can significantly enhance follow-up care for patients who are hard to reach after hospital discharge. The research highlights the effectiveness of integrating texts, automated messages, and live phone calls in supporting patients’ recovery processes.

After discharge, patients require a comprehensive treatment plan that may include medication management, laboratory tests, and access to community services. Many hospitals struggle to maintain contact with patients during this crucial period, which can impede their recovery. The study aims to address these challenges and improve patient outcomes.

Collaboration for Comprehensive Care

At UCSF Health, a collaborative effort among the nursing, social work, and pharmacy departments ensures that discharged patients receive continuous support. For instance, if a patient has not filled a newly prescribed medication, their nurse may consult with a pharmacist to verify medication status and confirm the patient’s understanding of their prescriptions. Additionally, social workers may assist in coordinating local food delivery or housing support for patients facing such challenges.

According to Lena Compton, RN, MS, and nurse coordinator for Care Transitions Outreach, “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, spearheaded by the Care Transitions Outreach nursing team, indicated that traditional automated phone calls were less effective for reaching African American patients. The standard outreach method managed to connect with only 70% of patients in this demographic, compared to an overall rate of 80%.

“There was a significant disparity when we evaluated how our program reached patients based on race and ethnicity,” stated Meg Wheeler, RN, MS, manager of Care Transitions Programs. “We realized that we weren’t supporting certain populations effectively, and that meant they weren’t getting the help they needed.”

To rectify this gap, the team adopted an integrated outreach approach. They implemented automated SMS text messages for all patients while pairing them with live phone calls for those who could not be reached via text. The results showed a marked increase in engagement, particularly among African American patients, with response rates rising to 76.4%. Overall, outreach success for all patients improved from 80.2% to 83.7%.

The findings were published in the Journal of General Internal Medicine in November 2025, underscoring the importance of tailored communication strategies in healthcare settings.

As healthcare systems strive to bridge the gap in follow-up care, this study emphasizes the critical role of effective outreach methods. By understanding and addressing the unique needs of diverse patient populations, healthcare providers can enhance recovery outcomes and ensure that no patient falls through the cracks.