MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care

NCT05245773 | Completed

• 1 other identifier: 849348
• Study Type: interventional
• Target: 5,000
• Locations: 1 country
• Sites: 1

Brief Summary

This study will evaluate a 30-day post-discharge intervention using an automated SMS platform to monitor patients and facilitate communication with their primary care practice. The population will be patients who receive care from participating practices and are discharged from an inpatient stay. In addition to the usual phone call from their practice, patients will be randomized to enrollment in the program, wherein they will receive automated SMS messages on a tapering schedule over 30 days.

Conditions

Care Transitions

Keywords

Post-Discharge; Primary Care; Automated Hovering

Outcome Measures

Primary Outcomes (1)

• Post-discharge acute care utilization

  A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.

  30 days post-discharge

Secondary Outcomes (7)

• Post-discharge days in the hospital

  30 days post-discharge

• Post-discharge acute care utilization

  7 and 60 days post-discharge

• Post-discharge ED visit

  7, 30, and 60 days post-discharge

• Readmission

  7, 30, and 60 days post-discharge

• Time from discharge to first acute care visit

  30 days post-discharge

Study Arms (2)

30-day automated hovering + usual care

EXPERIMENTAL

The intervention arm will get the usual post-discharge call from their practice, typically within 2 business days of discharge. In addition, they will be enrolled in the 30-day automated texting program, wherein they will receive check-in messages on a tapering schedule; they will be free to opt out at any time. They can also message into the platform at any time. Any needs identified through the platform will be escalated to their primary care practice, and they will receive a follow-up phone call from practice staff to address their needs.

Other: Automated SMS program to support post-discharge transitions of care

Usual care

NO INTERVENTION

The control arm will continue to receive the usual post-discharge call from their practice, typically within 2 business days of discharge.

Interventions

Automated SMS program to support post-discharge transitions of care OTHER

The intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team. After initial enrollment messages, patients will receive check-in messages on a tapering schedule over the course of 30 days. For the first week they will receive 3 total messages; the second week they will receive a total of 2 messages. For the last 2 weeks they will receive weekly messages. If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call. Patients will be able to reach out at any time by sending a message to the same number, and they will be entered into the same pathway. For any escalated need, patients will receive a follow up phone call from the practice staff.

Also known as: MORE-PC

30-day automated hovering + usual care

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• The study subjects will be medium to high risk (UPHS risk score 4 and above; an internally developed and validated score assessing a patient's risk for readmission) adult (age ≥ 18) patients of the Penn Primary Care Practices who are discharged home from acute inpatient care in the broad Philadelphia region as identified in HealthShare Exchange (HSX) reports

You may not qualify if:

• This study will exclude discharges who do not meet criteria for transitional care management. These criteria include discharges after 1) planned chemotherapy admissions; 2) certain scheduled surgeries, including spinal surgery, joint replacements, gastric bypass, transurethral resection of the prostate, gynecologic surgeries, and transplants; 3) obstetrics admissions.
• We will exclude patients from re-enrollment during the study period (once they have been enrolled once, they will not be enrolled again). We will also exclude patients being discharged to home hospice.

Sponsors & Collaborators

• University of Pennsylvania: lead
• UnitedHealth Group: collaborator

Study Sites (1)

University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania, 19104, United States

Location

Related Publications (1)

• Bressman E, Long JA, Burke RE, Ahn A, Honig K, Zee J, McGlaughlin N, Balachandran M, Asch DA, Morgan AU. Automated Text Message-Based Program and Use of Acute Health Care Resources After Hospital Discharge: A Randomized Clinical Trial. JAMA Netw Open. 2024 Apr 1;7(4):e243701. doi: 10.1001/jamanetworkopen.2024.3701.

  PMID: 38564221 DERIVED

Study Officials

• Anna Morgan, MD, MSHP

  University of Pennsylvania

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: Pragmatic randomized controlled trial with intervention and control arm

Study Record Dates

• First Submitted: February 8, 2022
• First Posted: February 18, 2022
• Study Start: March 29, 2022
• Primary Completion: January 4, 2023
• Study Completion: February 3, 2023
• Last Updated: February 27, 2023

Record last verified: 2023-02

Locations

US (1)