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

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.