摘要：Objectives. We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows. Methods. We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation. Results. Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI] = 2.2, 17.8; P = .01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI = −0.4, 6.4; P = .08). Conclusions. Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings. Homeless persons are sicker and die younger than those with stable housing. 1–5 Despite poor health, homeless persons underutilize primary care. They use emergency department (ED) care 3 times more often 6 and are hospitalized 4 times more often than are those in the general US population. 7,8 Homeless veterans, who number 62 000, 9 are in similarly poor health. 10 Despite substantial outreach efforts, 11 rates of missed medical appointments (“no-shows”) among homeless persons are high 12,13 ; for example, a study of homeless patients with tuberculosis reported 47% missed a first follow-up appointment. 14 Studies of causes of appointment no-shows indicate that forgetting about the appointment is the most commonly cited reason (19%) followed by being unaware there was an appointment (15%). 15 Outside the Veterans Affairs (VA) homeless population, a promising means of improving patient engagement with outpatient care has been through mobile phone text messaging, for example for appointment keeping 16 and getting vaccinated. 17 It is not known, however, how well text messaging would work with homeless populations. To our knowledge, this pilot study represents the first step in addressing this knowledge gap. We assessed the feasibility of using mobile phone text messaging to remind homeless veterans of their outpatient appointments. There is growing evidence that homeless persons increasingly have mobile phones. Even among a sample of street homeless, 44% had mobile phones in 2009. 18 A review of the literature on technology use by homeless persons found that mobile phone ownership ranged from 44% to 62% and computer access and use ranged from 47% to 55%, 19 and a recent study of young adult homeless found that 93% used Internet technology (e-mail, Internet, computer, or social networking) at least weekly. 20 We developed a text-messaging intervention called Texting Intervention for Linkage and Engagement and piloted it in an urban VA homeless-oriented primary care clinic in preparation for a larger-scale trial. 21 Pilot testing in this population is especially important, as their lives, compared with those of most study populations, include more complexities, such as unpredictable daily schedules, many competing needs, access to fewer communication channels, and high prevalence of mental health conditions and substance use disorders. We conducted the pilot study to evaluate whether text messaging is a feasible, effective, and acceptable means of reaching homeless veterans and to assess the suitability and ease of collection of our process and outcome measures. We investigated whether the intervention merits a larger study. 22–24 If text messaging is found to be feasible and effective, it would provide a low-cost, efficient means of reaching many veterans who are homeless—increasing their engagement in outpatient care and potentially improving their health and reducing their utilization of expensive ED and hospital care.
