JMIR Publications

ABSTRACT

Background:

Reducing 30-day hospital readmissions has been a longstanding goal across health systems in the United States. While nurse-led phone outreach has been widely adopted to support transitional care, its reach is constrained by staffing and time limitations. Mobile health (mHealth) interventions, such as automated text messaging and patient portals, offer scalable alternatives but have shown mixed effectiveness in reducing readmissions. Understanding how patients engage with mHealth after discharge may help optimize these tools for post-discharge care.

Objective:

This study aimed to characterize patients in an mHealth transitional care program who experienced hospital revisits within 30 days of discharge, comparing demographic and clinical characteristics, inter-visit interactions, and revisit features between those who engaged with mHealth and those who did not.

Methods:

We conducted a secondary analysis of patients in the intervention arm of the Mobile Outreach to Reduce Emergencies–Primary Care (MORE-PC) randomized clinical trial. Participants received automated text messages for 30 days after discharge alongside usual transitional care. We identified patients with a 30-day hospital revisit and used chart review to assess mHealth engagement as well as other forms of health care contact. We compared patient characteristics, inter-visit interactions, and revisit features (time to revisit, relatedness to index hospitalization, and predictability of revisit) between mHealth users and non-users.

Results:

Among 496 patients with a 30-day revisit, 185 (37%) engaged with mHealth before their return. mHealth users were younger (26% <50 years vs 14% among non-users; P = .004) and more likely to have commercial insurance (23% vs 11%; P = .005). Revisits were more predictable among mHealth users (56% vs 49%; P = .04), while relatedness to the index hospitalization was similar (53% vs 55%; P = .09). mHealth users had a longer mean time to revisit (15.2 vs 11.3 days; P < .001) and were more likely to also contact their practices via telephone (54% vs 44%; P = .03) or attend a clinic visit (61% vs 42%; P < .001).

Conclusions:

Among patients enrolled in an mHealth post-discharge program who experienced hospital revisits, fewer than half engaged with mHealth prior to their return. Revisits among mHealth users occurred later and were more predictable, suggesting that engagement may enhance situational awareness but not necessarily prevent revisits. Future work should focus on strategies to increase engagement across groups and integrate mHealth with existing transitional care infrastructure.