Using Bi-Directional Text Messaging to Engage Patients

Tracy Angelocci, MD; Chief Medical Officer, CareMessage

In March 2023 I presented on Using Bi-Directional Text Messaging to Engage Patients in Chronic Disease Management as part of the National Association of Community Health Centers (NACHC) Million Hearts® Learning Lab. Below, I have summarized some key points from this presentation, with a focus on the effectiveness of text messaging for improving health outcomes, and special considerations for ensuring successful delivery of messaging to historically-underserved patients.

Text Messaging Improves Health Outcomes

The average American has only four primary care visits per year, representing under two hours of face-to-face time with their provider. However, effective health management, especially of chronic conditions, requires many touch points for education, to build confidence, and teach disease self-management skills.

The Community Preventive Services Task Force (CPSTF), an independent panel established by The Department of Health and Human Services more than 25 years ago, reviews the evidence on community-based health promotion and disease prevention approaches. Having reviewed available evidence on patient texting, the CPSTF concluded that texting is helpful as an intervention in specific situations such as medication adherence, chronic condition management, improving cancer screening rates, and smoking cessation.

CareMessage is actively involved in building a body of evidence related to text messaging and patient health outcomes, conducting randomized controlled trials with University and Federally-Qualified Health Center (FQHC) partners. In a study examining diabetes management, a 12-week diabetes education text messaging program with low-income Latino patients at two FQHC sites in Los Angeles found that the intervention group had an average HbA1c reduction of 0.4 percentage points as compared to the control group (who received no messages). The subset of patients who were more highly engaged in the text program, responding to a greater number of the question prompts, achieved a significant mean HbA1c reduction of 2.2 percentage points.

CareMessage is an expert in best practices on developing messaging content that drives patient action. In order to improve effectiveness, messaging content should be personalized, and should incorporate theories of behavior change. Bi-directional, branching text message sequences can:

• ask patients questions
• be responsive to the input that patients provide, and
• nudge patients toward action with a tailored combination of education and calls-to-action.

Content should reflect a combination of patient-centricity and clinical focus. For that reason, we strive to communicate with patients in their preferred language and at a digestible reading level, while also reviewing and updating our content on an ongoing basis to be grounded in the latest clinical evidence.

Ensuring Reach and Deliverability of Messaging

Digital access and digital literacy are often cited as concerns in effectively reaching patients, but Short Message Service (SMS) texting is a great equalizer. SMS texting requires only cell phone carrier coverage, and does not require internet connection or a device any more complex than the most basic flip phone. The latest Pew research shows that 97% of Americans now own a cell phone that can receive SMS texts.

Smartphone ownership has risen to 85%, with smartphone ownership being equivalent across racial and ethnic groups. However, smartphone ownership is significantly lower in some specific segments of the population:

• 61% for those over age 65
• 76% for households with annual incomes under $30,000
• 80% in rural areas

When messaging patients, we should keep in mind that a significantly higher percentage of adults over age 65, in rural areas, and at lower income levels will not be able to access mobile apps, or access the internet on their phones. In order to ensure that messaging is seen by patients, it’s important that SMS texting is used, and that patients are not simply sent links to a portal or app that requires login or download in order to view. Care should be taken in asking patients to fill out forms or provide sensitive information, such as birthdate or social security number, in order to view messages. Being mindful of barriers to accessing messaging content can help prevent exacerbating disparities or furthering health inequities in underserved populations.

Operationalizing Text Messaging for Health Centers

Incorporating a patient texting strategy does often require re-prioritizing staff time and additional training, but provides a compelling return on investment.

Health centers that engage with patients via text message are able to reduce appointment no-show rates and quickly perform outreach to newly assigned Medicaid, ACO, and Medicare MCO patients to book their first appointment. Texting campaigns can be effective in closing care gaps, which is obviously important from a clinical standpoint, but which can also contribute to improved clinical metrics and performance in value-based contracts. Patient satisfaction ratings, another key component to successful performance in value-based contracts, can be monitored in a cost efficient way by surveying via text.

Here are some best practices for operationalizing text messaging in your organization:

• Track your texting strategy: Examine the impact that adding a texting platform has on staffing ratios, time spent closing care gaps and processing referrals. Test and learn, and choose a texting platform that offers a Customer Success team who can advise on strategies to meet your goals.
• Focus on developing staff: Career growth can be achieved as staff move from patient services reps, to a deeper focus on facilitating population health. Staff satisfaction and patient satisfaction increase as communication is simpler and more trackable.
• Measure return on investment: Examine changes to identified key metrics such as the volume of patients scheduling appointments and no-show rates. Consider a tool that does not charge per message, so that you can increase the volume of messaging to drive patient action without any incremental cost.
• Partner with your PCA or HCCN:These associations are great resources for helping to select and operationalize bi-directional text messaging platforms, and may offer discounted pricing.
• Choose a platform that is a compliance and regulation expert: It’s important that texting vendors are up-to-speed not only on HIPAA, but also TCPA (the federal Telephone Consumer Protection Act) and individual cell carrier regulations. Your text messaging vendor should be able to provide messaging workflows that are based on the latest regulations.