Spread of a heart failure remote patient management program from speciality to community care settings: multiple case study implementation

Abstract

Background

The Medly remote management program, which has demonstrated effectiveness in a speciality care setting, enables comprehensive management of patients with heart failure by integrating the Medly digital therapeutic with defined clinical roles. One-time funding from Ontario Health was awarded to 3 community-based organizations to implement Medly for the first time outside a speciality care setting. The objectives of this project were to evaluate implementation success and identify the facilitators and barriers to implementing this intervention in 3 community-based settings.

Methods

A multiple case study approach was used to determine implementation success using the Proctor implementation outcomes and barriers and facilitators based on constructs of the Consolidated Framework for Implementation Research (CFIR). Qualitative insights were collected through semi-structured interviews (n = 20) with implementation team members 3 months after enrollment of the first patient. Quantitative data for the implementation outcomes were obtained from a secondary analysis of project status reports analyzed 6-months after go-live.

Results

Although there was evidence of intervention fidelity and perceptions of acceptability and appropriateness toward the Medly program at all 3 sites, implementation of the Medly program was found to be successful at only one site based on the key Proctor outcomes of feasibility and adoption. The interviews revealed common implementation facilitators across sites related to characteristics of the intervention, including relative advantage and intervention design quality. Between-site differences related to the CFIR constructs of the inner and outer setting highlight unique features that resulted in differing levels of implementation success. Specifically, facilitators included access to a predefined patient pool, maturity of the organization and communication channels and staffing resources while barriers included lack of time to execute the implementation plan as intended.

Conclusion

This work demonstrates that remote management programs, like Medly, can be translated from a speciality care setting and implemented with fidelity in community settings. However, certain contextual conditions are important to enhance the likelihood of success of the implementation, particularly when time constraints are imposed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14875-7.

Contributions to the Literature

• Digital health solutions are becoming increasingly prevalent in the healthcare space and previous studies have shown that remote management programs can help improve patient outcomes.

• Implementing programs in community settings, particularly with rural populations, involve unique considerations and this project highlights the facilitators and barriers to implementing an innovative remote management system in these environments.

• Identifying the features that contribute to the success of a remote management system implementation in the community such as ensuring adequate time, organizational maturity with established communication channels, dedicated clinical resources, among other contextual elements can help with adapting the current model and inform future planning for similar innovative programs.

Background

Heart failure (HF) is an increasingly prevalent chronic condition which directly impacts approximately 650,000 Canadians [1]. In addition to the burden of disease on patients and families, the high hospitalization rates pose a significant challenge for healthcare systems. To address this, the Medly remote patient management program was developed and implemented at the University Health Network (UHN), a leading speciality center for cardiac care in Toronto, Canada, to enable better self and clinical management of HF [2–4].

Telemonitoring (TM) has been shown to be effective in outcomes such as reducing all-cause mortality, health utilization, and patient quality of life [5–9]. However, even if an intervention is proven effective in one setting, generalizability to other settings is not guaranteed. For example, patient population demographics, access to care, and resources to support remote care differ in rural settings as compared to urban centers which may impact implementation success. Furthermore, adaptations to the intervention are likely required to achieve better fit with the local context but these adaptations pose a risk to program efficacy if the adaptations encroach on fidelity to the original evidence-based intervention.

The Medly remote management (RM) program is a Health Canada approved class II medical device that combines a smartphone-based platform involving a clinically-validated expert rules-based algorithm with an integrated nurse-led model of care. Patients enter daily metrics and the rules-based algorithm provides immediate feedback to users, reassuring them of a stable condition or advising them to take an additional diuretic dose and/or to seek assistance from their primary care provider/cardiology clinic, or emergency services if there was significant derangement based on prespecified, individualized parameters. The rules-based algorithm also triggered an automated email alert to a dedicated nurse coordinator and the patient’s treating cardiologist if values exceeded the parameter limits. A pragmatic evaluation of the Medly program which has been part of standard of care at UHN since 2016, demonstrated significant improvements in patient self-care, quality of life, clinical outcomes, and in addition to a 50% reduction in HF-related hospitalizations [10]. Despite these positive results in a speciality care setting, there is an opportunity to learn about the factors that influence the scale and spread of this evidence-based innovation to remote and rural community-based settings.

Ontario Health Teams (OHTs) are part of an integrated care model implemented by the Ontario government which aims to increase collaboration and streamline care among health providers for a particular population of patients [11]. In the summer of 2021, two OHTs and one Indigenous primary care team serving largely rural and smaller communities in Ontario, Canada received one-time funding to implement the Medly program. OHTs and Indigenous primary care teams represent the formal grouping of health and community service organizations, typically clustered within a geographic area, with the objective of providing integrated care to its population. OHTs are the product of ongoing restructuring of the Ontario health system which began in 2019 and as such, OHTs are in varying stages of maturity. This project represented a unique opportunity to study the first external implementations of the Medly program in an integrated care community setting.

Our objective was to evaluate the implementation of the Medly program by answering the following research questions: [1] To what degree was the Medly program successfully implemented in the 3 community settings?; and [2] What were the barriers and facilitators to the respective implementations?

Further, this work sought to inform the scale and spread of complex digital interventions such as Medly by:

1. Refining our understanding of the core components of HF remote management programs through the process of planned adaptation to foster fit within a community setting.

2. Executing and refining a phased multi-component implementation strategy for deploying remote patient management interventions in a community setting.

3. Documenting unique barriers and facilitators to implementing innovations in emerging integrated care settings such as OHTs.

Methods

Study design

This study used a mixed-method multiple case study design to evaluate the success of the Medly program implementation at different sites and identify the factors that may have contributed to this outcome. The cases were defined as the 3 implementation sites (Couchiching OHT, South Simcoe (SS) OHT, and Mamaway Wiidokdaadwin). The study period spanned September 2021 (announcement of project funding) to August 2022 (6 months after the date of first patient enrollment). This work was approved by the UHN Quality Improvement Review Committee (QI ID: 22–0377). The project was developed in accordance with the SQUIRE 2.0 checklist [12] and an additional file shows this in more detail [see Additional file 1].

Intervention

The Medly program combines a digital therapeutic called Medly (regulated by Health Canada as a Class II Medical Device) with a model of care that has been designed to improve patient self-care and clinical management to ultimately lead to improved HF outcomes, better quality of life, and reduction in health service utilization. It has been demonstrated to have successfully been implemented in a tertiary care urban centre at the University Health Network (UHN) in Toronto, Ontario [4]. Details regarding this implementation, including a logic model and evaluation have been discussed elsewhere in the literature [10, 13–14].

Improved patient self-care is achieved through 2 key mechanisms resulting from patients using the Medly smartphone application (Fig. 1) to record daily weight, blood pressure, heart rate, and HF symptoms. First, the act of taking daily readings brings visibility to key HF physiological metrics needed for self-management. Second, a clinically validated rules-based expert system (which can be customized to the patient by the care team through the setting of target thresholds and medication prompts) immediately processes inputs and provides actionable self-care feedback to the patient (e.g. if a patient alerted for increased weight, the patient may be prompted to take an additional dose of a prescribed diuretic, if appropriate and as pre-set by the clinical team). This algorithm functions 24/7.

Fig. 1.

Medly patient application depicting examples of patient feedback following daily readings

The clinical model of care, which is enabled by the algorithm, improves clinical management through 3 mechanisms. First, by providing automated clinical directives to patients, the algorithm manages the majority of clinical alerts and alerts the frontline clinician (i.e. Medly Coordinator) in real time when needed through the dashboard and via email. This enables the Medly Coordinator to identify and make rapid contact (typically within 0–3 h) with the most urgent cases. Remote interactions with patients (either over the phone or using the secure in-app messenger) allows the Medly Coordinator to gather more information and offers an opportunity to provide patient education at “teachable moments” [15]. Second, when changes to a care plan are needed, the Medly program enables fast access to clinicians with appropriate scope of practice (e.g. NP or MD). Finally, longitudinal data provides a better picture of patient health status between checkpoints to better inform in-person and virtual visits (Fig. 2).

Fig. 2.

Medly clinician dashboard depicting longitudinal patient data

To summarize, the Medly program combines a regulated digital therapeutic that promotes patient self-care (through daily monitoring, automated feedback, and actionable prompts) with a responsive model of clinical management (enabled by real-time alerts, rapid clinician access, and longitudinal data) to improve heart failure outcomes, enhance quality of life, and reduce health service utilization in community settings. Table 1 shows the core components of the Medly program (i.e. those with limited adaptability to ensure fidelity) and the intervention components that were adapted to enhance context fit across the 3 Sites.

Table 1.

Intervention components per site

Intervention Characteristic	Couchiching OHT	South Simcoe OHT	Mamaway
Core: Medly Software	Same as UHN	Same as UHN	Same as UHN
Core: Medly Coordinator (rapid response to alerts)	Existing RN at FHT Heart Function Clinic	Existing RN at FHT	Newly hired RN
Core: Medly MRP (rapid changes to care plans)	RN with medical directives for HF medication titration + access to FHT internists	NP or internist at nearby hospital	Champion PCP
Adaptable: Primary Source of referral	Existing patients of FHT	Community PCP; hospital discharge	4 affiliated by geographically disparate primary care clinics
Adaptable: Modality of patient-clinician communication	Phone + Medly messaging feature	Phone	Phone
Adaptable: Clinician monitoring hours	Clinic office hours (8am – 4pm, Monday to Friday)	Clinic office hours (8am – 4pm, Monday to Friday)	Clinic office hours (8am – 4pm, Monday to Friday)
Adaptable: Equipment	BYOD preferred; Equipment available if needed	BYOD preferred; Equipment available if needed	BYOD preferred; Equipment available if needed
Adaptable: Frontline Technical Support	Medly Coordinator (RN)	Medly Coordinator (RN)	Office manager

BYOD: Bring your own device; FHT: Family Health Team; MRP: Most Responsible Physician; NP: Nurse Practitioner; OHT: Ontario Health Team; RN: Registered Nurse; UHN: University Health Network

Study sites

A purposive sampling strategy was used to select study sites. The 3 cases were the only community-based organizations that received one-time funding from Ontario Health to implement the Medly program in the 2021–2022 funding cycle following a review of proposals which included targets for patient enrollment. All sites served largely rural or semi-rural populations and were included because they represented the first implementations of Medly outside of a specialty care setting. Portions of the funding were at risk of claw-back if enrollment targets were not met by the expected date of March 31st, 2022.

Study site 1: Couchiching OHT

The Couchiching OHT, which serves the communities of Orillia, Oro-Medonte, Rama First Nation, Ramara, and Severn, ON, is a mature OHT that serves semi-rural and rural populations. It includes a formal alliance between the Couchiching Family Health Team (FHT), Orillia Soldiers’ Memorial Hospital, and several community organizations. The Medly program was based at the Couchiching FHT Heart Function clinic which is a community-based outpatient clinic for patients having HF with preserved and reduced ejection fraction. The Couchiching FHT had an existing caseload of approximately 380 patients and had an enrollment target of 100 to 120 patients in 6 months.

Study site 2: South Simcoe OHT

The SS OHT (now the North York South Simcoe OHT) is a newly amalgamated OHT that serves a wide region of semi-rural and rural populations across York Region and Simcoe County with the goal of establishing a formal alliance with the Alliston FHT and Stevenson Memorial Hospital (both located in the Municipality of Alliston, ON), along with other community organizations. The Medly program was initially designed to span both the Alliston FHT and Stevenson Memorial Hospital in a shared model whereby daily monitoring would be conducted by a nurse at the FHT with escalation pathways to a nurse practitioner at the hospital. The SS OHT had an initial enrollment target of approximately 150 patients over 6 months.

Study site 3: Mamaway Wiidokdaadwin

Mamaway Wiidokdaadwin (Mamaway) is an Interdisciplinary Primary Care Team serving an Indigenous patient population and is one of multiple service delivery organizations of Barrie Area Native Advisory Circle (BANAC). Mamaway operates in two clinics located in municipalities of Barrie and Orillia and at the time of the initial implementation, nurse practitioner services extended to Beausoleil First Nation Health Centre (Christian Island, ON) and Rama First Nation Health Centre (Rama, ON). Mamaway serves Indigenous peoples across North Simcoe County and Muskoka Region, ranging from semi-rural to remote communities and including people living on a reserve as well as people living off a reserve. Prior to launch, there were approximately 60 patients with HF being followed by Mamaway. Mamaway had an enrollment target of 30 patients for the Medly program over 6 months.

Implementation process

A multicomponent implementation strategy, made up of discrete strategies from the Expert Recommendations for Implementing Change (Table 2), was executed across 4 phases: (1) Engagement and Needs Assessment (2), Program and implementation plan customization (3), Execution of the implementation plans, and (4) Monitoring and Refinement. Importantly, some activities in the phase 1 were not possible due to Covid-19 restrictions (e.g., in person engagement meetings and workflow mapping) and others were compressed (e.g., comprehensive needs assessment) due to a sense of urgency to begin enrollment patients to ensure the meeting of targets.

Table 2.

Evidence-based strategies used to guide the medly program implementation

ERIC Strategy	Description	Phase
Build a coalition	An implementation team (IT) was formed at each of the 3 sites consisting of respective clinical and administrative stakeholders and members of the UHN with expertise in the Medly program and digital health implementation.	Engagement and Needs Assessment
Identify and prepare champions and early adopters	Champions, both clinical and administrative, were identified and played a central role on the IT.	Engagement and Needs Assessment
Organize clinician implementation team meetings	Weekly IT meetings began from the time of the project kick-off until 1 month after enrollment of the first patient with frequency of meetings dropping to monthly thereafter.	All phases
Assess for readiness and identify barriers and facilitators	Potential barriers and facilitators were probed during meetings with IT members using questions based on the CFIR.	Engagement and Needs Assessment
Conduct local needs assessment	Local needs assessment began during the initial proposal development and continued as the IT collaborated to design the best pathways to meet local needs.	Engagement and Needs Assessment
Obtain formal commitments	Sites entered into a formal agreement with Ontario Health related to enrollment targets and funding and a second Software-as-a-Service agreement with UHN.	Engagement and Needs Assessment
Develop a formal implementation blueprint	A detailed implementation plan was drafted for each site to ensure alignment between implementation team members. The plan articulated the site-specific aim of the implementations, scope for the change, implementation activities, and timelines.	Program and implementation plan customization
Tailor strategies	Implementation strategies were tailored and operationalized differently to address site-specific needs and barriers.	Program and implementation plan customization
Promote adaptability	Core and adaptable components were identified a priori. Adaptable components were modified based on the outputs of Phase 1. The adaptations were codified into site-specific standard operating procedures which maintain the fidelity of the core components.	Program and implementation plan customization
Conduct ongoing training	Training of clinical and administrative staff was delivered by a UHN nurse with experience using the intervention. Follow-up training sessions were delivered as needed.	Execution of the implementation plan
Change physical structure and equipment	Storage areas for Medly equipment were identified at each site.	Execution of the implementation plan
Change record systems	Ontario Health required sites to report monthly process metrics and end-of-project outcome data. Some sites use manual spreadsheets whereas others created customs EMR forms to track these metrics.	Execution of the implementation plan
Provide ongoing consultation	The UHN team provided ongoing consultation related to implementation and the use of Medly both within and outside IT meetings.	All phases
Purposely reexamine the implementation	The IT continued to meet after go-live and integrated on the clinical service based on experiences. Sites were provided with data that was collected regarding the implementation.	Monitoring and Refinement

CFIR: Consolidated Framework for Implementation Research; EMR: Electronic Medical Record; IT: Implementation Team; UHN: University Health Network

Data collection: Interviews

Within each site, a total population approach for recruitment was used by inviting all individuals who attended regularly scheduled implementation team meetings and were agreeable to participate in the interviews (n = 20). Semi-structured interviews with the Implementation Team and program staff were conducted between 3 and 5 months after the onboarding of the first patient in the program. The guide for the interview questions was developed for this study [see Additional file 2]. Implementation Teams were made up of internal project stakeholders (i.e., relevant project management, clinical, and administrative staff at each site) and external facilitators (i.e., UHN staff with experience implementing the Medly program.) Sample size was based Interview questions were drafted based on constructs of the Consolidated Framework for Implementation Research (CFIR) which is a determinant framework that classifies barriers and facilitators to implementation within the domains of [1] Characteristics of the intervention; [2] Outer Setting (i.e. contextual factors unrelated to the site), [3] Inner Setting (i.e., characteristics of the sites), [4] Characteristics of individuals involved, and [5] Implementation process. Additional questions also probed areas of improvement for the program and Implementation Outcomes of Acceptability and Appropriateness. Interviews ranged between 30 and 60 min and were recorded and de-identified at the time of transcription.

Data collection: Implementation outcomes

An assessment of the degree of implementation success 6 months post-go live at each site was based on implementation outcomes in the Proctor et al. [16] framework. Quantitative data from mandatory monthly reports and qualitative data from semi-structured interviews were collected concurrently with narrative weaving of results for a holistic determination about implementation success at each site. The Proctor implementation outcomes were assessed as described below (Table 3).

Table 3.

Proctor implementation outcomes definitions and data collection methods

Proctor Outcome	Definition	Data Source	Variables/Indicators Used
Feasibility	Extent to which the Medly program can be successfully carried out.	Administrative Data	-Number of patients enrolled in program -Number of patients discharged from the program
Fidelity	Degree to which the core components of the Medly program are operating as intended and in accordance with the implementation plan.	Administrative Data and Interviews	Holistic interpretation that combines: -Number of escalations and touchpoints between the patient and clinical team (a proxy for key program roles being performed as intended) -Views expressed during the interviews related to perceptions of the intervention operating as intended This interpretation is captured as ‘yes’ (i.e., implemented with high fidelity), ‘no’ (i.e., implemented with poor fidelity), or unclear, (conflicting information preventing the drawing of clear conclusions)
Adoption	Intention of clinicians to actively engage in the Medly program.	Administrative Data	-Number of clinicians who sent referrals and had active Medly accounts
Acceptability	Perception among implementation stakeholders that the Medly program is agreeable and/or satisfactory.	Interviews	-Coding from semi-structured interviews
Appropriateness	Perceived fit, relevance, or compatibility of the Medly Program.	Interviews	-Coding from semi-structured interviews

Data analysis

Numerical data for implementation outcomes including Adoption, Feasibility, and Fidelity, were obtained from a secondary analysis of the monthly reports which were part of the funding requirements. Interview transcripts were analyzed using deductive thematic coding by two investigators, AD and MO based on the CFIR constructs. After an initial round of independent coding based on the criteria outlined by Damschroder et al. [17], AD and MO met to compare themes and iteratively resolve discrepancies until a consensus among both investigators was achieved. Additional administrative data from the implementation and qualitative data from interviews for Proctor outcomes were coded by AD.

Results

Implementation success outcomes

Overall, implementation at the Couchiching site showed positive metrics across all Proctor outcomes assessed. Specifically, this included the uptake of the program by clinical staff, the number of patients enrolled (feasibility) outcome, and the compatibility with the site goals and current workflow (appropriateness). This was not as consistent across the Mamaway and SS sites. Of note, Couchiching did not have external referrals to the program as they enrolled from a pre-existing patient roster at the Heart Function Clinic.

Mamaway and SS experienced lower enrollment than initially expected while demonstrating evidence of intervention fidelity and evidence of perceived acceptability. This highlighted an opportunity to strengthen referral pathways at both sites which would have facilitated successful implementation of the program at these sites. The data used to assess each Proctor outcome assessed has been outlined in Table 4.

Table 4.

Implementation outcomes

Criteria	Couchiching	South Simcoe	Mamaway
Adoption
# of physicians having sent at least 1 referral	N/A	2	1
# of clinicians with a Medly account	4	4	6
# clinicians with an active role in remote management using Medly	2	2	2
Feasibility
# of referrals to the program	N/A	4	35
# of patients enrolled	46	4	7
# of patients discharged	13	1	3
Fidelity
Evidence of use of the Medly software according its indications for use	yes	yes	yes
Evidence of rapid response to Medly alerts	yes	yes	yes
Evidence of escalation and rapid changes to care plans	yes	yes	unclear
Acceptability*
Perception of Medly as satisfactory or agreeable	Couchiching Team Member 3: “ [The Medly Program] is fantastic for our people. For some of the older generation it is very difficult to use the phone, but that just comes with everything… I think it has prevented quite a few hospital trips.”	South Simcoe Team Member 1: “We really liked the Medly program and […] the functionality that it has. We realize that the funding that we have will only last a year. But we thought that the functionality was worth trying to make that work financially going forward.”	Mamaway Team Member 2: “I honestly like the way that it was introduced to me, the resources I was given, how it was implemented, I think it all went really well.”
Appropriateness*
Perceived fit, relevance, or compatibility of the Medly Program.	Couchiching Team Member 3:” I think [the Medly Program] is really good. It definitely has added work, but I think that was to be expected because you’re adding in another program.”	South Simcoe Team Member 6: “I think overall it’s meeting our current needs, and I think if Medly program expanded and we continued with more remote care monitoring as an OHT, we would be very happy with how it is and how it went.”	Mamaway Team Member 2: “I have a patient who struggled [daily]…with very high blood pressure where I was on the phone with them sometimes 3 times a day… [With Medly], I see patients being able to take a lead on their health care right because now they’re able to monitor what their bodies are doing every day and also determine what works, and what doesn’t.”

*Qualitative data for Acceptability and Appropriateness is taken from interviews conducted 3 to 5 months after the first patient was on boarded at each site while remaining quantitative data is from 6 months after implementation go-live

#: This symbol refers to ‘number’

Barriers and facilitators to implementation

A total of 20 implementation team members participated in the interviews, including 6 from Couchiching, 6 from SS, 3 from Mamaway, and 5 from UHN.

Table 5 serves as a structured synthesis of the key facilitators and barriers within each CFIR domain that were identified in the semi-structured interviews. Select quotes which help explain the degree of implementation success across the 3 sites are discussed in the sections below.

Table 5.

Strongest expressed facilitators and barriers within each domain for each site

Domain	Couchiching	South Simcoe	Mamaway
Intervention Characteristics	Facilitators -User-friendly interface -Unified belief from staff regarding perceived benefits of Medly program compared to alternatives available in the region Barriers -Inability to further personalize algorithm to fit clinician workflow	Facilitators -User-friendly interface for patients Barriers -Perception of currently available alternative programs filling similar needs to Medly -Complexity and time of performing additional tasks (e.g., completing referral forms from community providers)  -Lack of sustainable funding	Facilitators -User-friendly interface Barriers -Perceived sustainability from cost and funding perspective
External Context	Facilitators - Strong grasp of target user needs -Established patient roster Barriers -COVID preventing preliminary visit and set-up	Facilitators -Ontario Health supporting use of program Barriers -Lack of clarity regarding characteristics and needs of patient population -COVID preventing preliminary visit and set-up -Lack of connection with all physicians across regions	Barriers -Lower patient comfort with mobile technology than initially anticipated
Internal Context	Facilitators -Established nurse-led HF clinic to identify patients for enrollment -Additional staff hired to support implementation of the program -Positive feedback from patients using the program encouraging further efforts for recruitment and expansion -Organizational maturity with established communication channels	Facilitators -Positive team culture -Compatibility with goals of OHT of introducing digital health platforms into the system Barriers -New organisation (‘emerging’ OHT) without established patient base -No formalized communication channels between clinicians and administration team -Limited staffing  resources dedicated to Medly program	Facilitators -Organizational maturity with established communication channels and long-term connections between patients and providers -Additional staff hired to support implementation of the program Barriers -Geographic and staffing barriers at affiliated island-based community health site which was initially planned to be a base for patient recruitment.
Individuals’ Characteristics	Facilitators -Clinical staff comfort within organization and current role that permitted space for expanded scope -Strong motivation to help patients	Facilitators -Strong motivation to help patients	Facilitators -Strong motivation to help patients
Implementation Process	Facilitators -Strong engagement of local stakeholders and the project team -UHN implementation team support Barriers -Funding-dependent time constraints	Facilitators -UHN implementation team support Barriers -Lower stakeholder engagement due to staffing challenges and lack of formal communication channels -Funding-dependent time constraints	Facilitators -Strong engagement of local stakeholders and project team -UHN implementation team support -Early needs assessment to identify challenges

Intervention characteristics

Relative advantage

At the Couchiching OHT, staff were unified in its belief about the perceived benefits of the Medly program relative to alternative options available in the region.

Couchiching Team Member 5:“[The Medly program] is real time, that’s the advantage…There’s a bit of a lag [with other telemonitoring programs] because somebody’s not technically monitoring it …whereas, [with] Medly, the goal is if there is something out of the criteria set, you have the ability to provide real time feedback.

At SS, there was more variation in beliefs about the advantages of the Medly program, particularly among primary care providers (i.e. those responsible for referring) who saw similarities to other programs, such as the Home and Community Care program, that was already in place. The Home and Community Care program is a 6-month program initiated through the provincial health system focused on nurses providing patients with education for a fixed time duration based on monitoring vitals they have inputted.

SS Team Member 1: The other question that we got from the physicians was “Well, you know [Home and Community Care] already has a remote monitoring program for CHF patients so why are we doing this?

Design quality and packaging

All sites agreed that the Medly system is easy to use but suggestions for improvement were made for the program to better fit clinician workflows and patient needs outside of a speciality care setting. This includes opportunities for providing further information of the capabilities and benefits of the program for other clinicians.

Couchiching Team Member 4: We get a lot of ‘go to emerge’ alerts, which is an issue that we’re all working out. Those ones we do follow up with because they don’t always need to go to emerge…we have to call and be like “So, did you go?” That is kind of where it adds the most time.

SS Team Member 4: I think if they had a little more information on what [the program] could do… we would have had more intake of patients… I will say, I think a lot of it had to do with the referral form. They took a look at it and didn’t want to.

Mamaway Team Member 3: The only challenge right now is the screen size. Many others have expressed [that] seniors or community members can’t read the content very well so when they expand the size of a text on their phones the formatting is not working out as clearly on the app.

Outer setting

Patient needs and resources

Due to the established heart function program which included specialized nurses and a specific patient roster, the Couchiching site had the clearest grasp of the scope and needs of the target population, including how best to implement the Medly program to address those needs, especially patients living in a rural setting.

Couchiching Team Member 1: The folks that come into the heart function clinic, chances are [they are falling into]…categories of [a] “priority population”…So the Medly program helps to do an early identification of how the patients are doing better, monitoring them at home, and really looking at the goals of keeping them out of hospitals.

The Mamaway site initially believed they had several patients in their catchment who could benefit but experienced challenges identifying individuals that would be a good fit once the program was launched. This included consideration of technology literacy and comfort with the mobile application as a management tool.

Mamaway Team Member 3: I think we thought we had more people that would be on Medly. But … [as we assessed the criteria for Medly, we realized that not everyone was eligible and] we were really trying to not just sign somebody up just because we needed to meet a deadline.

Likely owing to the emerging status of the OHT, SS had less clarity about the target patient population in their region in terms of numbers and demographics of HF patients that could be enrolled in the program.

SS Team Member 3: One of the challenges we’ve been having is getting some of that data in terms of [hospital] admissions…We don’t have that [resource to acquire the patient demographics data] and I’m still trying to find who that person is.

Inner setting

Structural characteristics

The Couchiching OHT had an established nurse-led heart function clinic which made it easier to integrate the Medly program, particularly as it related to identifying patients for enrollment.

Couchiching Team Member 3: I think [it is] easier, maybe, that we are a HF program that we already have the patients. We don’t really have to identify anybody, we can just go down the list.

At SS, the primary issue was centered around the organization being relatively new and not having an established base of patients.

SS Team Member 1: We’re dealing with physicians who are not affiliated with our FHT. So that’s making it challenging.

At Mamaway, initial plans to refer patients from an affiliated island-based community health centre (Beausoleil) faced geographic and staffing barriers.

Mamaway Team Member 1: Our [Mamaway] NP [who supported the Beausoleil First Nation] has moved to [the] Orillia [clinic] because the position came up [which shifted our relationship with the island a bit over the course of the project]. [Beausoleil also has] their own health team and Mamaway’s always kind of attached to the side of it.

Networks and communication

The weekly implementation team meetings were perceived as an important facilitator across all 3 sites. However, the quality of within-site communication influenced the projects separately.

Couchiching Team Member 5: [COHT leadership is] very good at… letting teams know what’s happening [and] giving updates which I do think people appreciate so that it doesn’t come as a surprise. You know good news is shared, and we have staff check-ins.

SS Team Member 1: These physicians are not one big cohesive group…it’s new for these doctors to be having the FHT or the OHT coming to them and saying, “Oh, by the way, we now have this program for you.

At Mamaway, the communication channels were relatively fixed within the organization with regular meetings. Despite some early challenges connecting with individual physicians in the region, long standing relationships in the community helped counter the potential influence of this barrier.

Mamaway Team Member 1: Word of mouth gets out… They talk a lot which is great and feedback we’re having is “yeah this is [a] good [program]”.

Available resources

At Couchiching and Mamaway sites, there were additional staff taken on to help support the implementation of Medly and allow for a balance with other clinical duties. Although there continued to be some challenges with balancing the workload, there was more opportunity to expand the program.

Couchiching Team Member 1: This [heart failure] program has only ever ran with one [Registered Nurse]. We just started the [Registered Practical Nurse] role in January this year…I don’t think [the RN] could ever have done Medly program at the same time [as the heart failure program]. There’s just not enough hours in a day to figure it out.

Mamaway Team Member 3: In the beginning of the project we weren’t gonna hire a nurse coordinator, and it was gonna fall back on the registered nurses. But they did express that they didn’t have capacity…we ended up hiring the nurse coordinator with that feedback. So that was the one piece that was really key and I’m not sure if it would have been as successful without that direct contact.

At SS, there were concerns with staffing that resulted in challenges with having adequate clinical personnel and individuals to carry out other components of the implementation. The team was willing to take over roles as needed but lack of appropriate resources was a barrier.

SS Team Member 5: You’ve got so much in kind that’s donated to the projects, and that’s a resource that is tight.… I was supposed to hire staff for my component but I couldn’t, we weren’t successful in our recruitment…So human resources in any of the projects that I’ve worked on in the digital health from these funding has been a huge challenge, and very much impacting the success of the projects.

Process

Engaging key stakeholders (providers and staff)

At Couchiching and Mamaway, the level of engagement of local stakeholders was perceived as high and an important facilitator to the project.

Couchiching Team Member 6: Engagement on our end has been excellent in terms of participation in the project team, partnership with UHN, support in and around evaluation and in terms of the clinical support.

UHN Team Member 5: Everybody really came together (at Mamaway) to identify patients in their local practices and across the different clinics. And they were really going through the lists and identifying people and approaching people [that met criteria for the program].

At SS, the lack of formal communication channels and staffing changes led to more limited engagement.

SS Team Member 2: At the beginning I didn’t even really know about the Medly program until the Nurse [previously identified for the role] was leaving.

External change agents

All sites agreed that the implementation team from UHN provided strong support throughout the implementation process and had clear implementation ideas and onboarding resources.

Couchiching Team Member 5: I would say the Medly team, from UHN was phenomenal. Especially their ability to offer themselves, certainly being highly available, having the weekly meetings that have now transitioned to monthly…I think they’re overall understanding of the program.

SS Team Member 6: Great support from the Medly team. I think that was just something that made it successful to implement. We had every single question answered, we had people available right away.

Mamaway Team Member 2: Our working relationship with UHN assisted us with implementing the program.

Executing

The implementation strategy at all three sites was planned and iterated upon in collaboration with local stakeholders as the projects progressed. Overall, most activities were executed as planned with the exception of the needs assessment and engagement activities which, according to most members of the implementation team at SS, felt rushed. For the emerging SS OHT, there was a tension between the need to achieve funding-dependent enrollment targets with the fact that more groundwork would have been required to bring the local context to an adequate state of implementation readiness.

UHN Team Member 1: The model [at SS] required family physicians within the OHT to refer into the program [which] requires communication to them, and raising awareness that the program exists and what it can do. Given the time constraints, I don’t think there was enough time to have that communication go out to the family providers. […]and the fact that there’s slow referrals means you’re not really given an opportunity to learn and to improve the program operations.

SS Team Member 1: The first [opportunity to improve the process] would be to take more time. It was too rushed. I think, particularly for our team, there needed to be a more targeted communication piece involved.

Discussion

Principal findings

This study aimed to determine the degree of success for implementing the Medly remote management program, developed and evidenced in an urban speciality care setting, into 3 rural and semi-rural community settings. Based on the holistic analysis of the implementation outcomes of adoption, feasibility, fidelity, acceptability and appropriateness, the Couchiching site had a successful implementation of the Medly program while the SS and Mamaway did not. Although all 3 sites were found to be delivering the intervention with fidelity and stakeholders found the program to be acceptable and appropriate, implementation at the Couchiching site demonstrated that Medly was adopted as intended and found to be feasible.

The other two sites, Mamaway and SS, experienced greater challenges with the engagement of referring providers which highlight the importance of focusing on this component during implementation planning and collaboration with the community. Thematic analysis based on the CFIR constructs helped to guide an understanding of what defines a healthy implementation context and readiness to accept the program.

Intervention characteristics

All sites agreed that the program was well-designed. Despite room for improvement in terms of tailoring to algorithm messages and referral processes, a clear understanding of the intervention’s modifiable components enabled implementation teams to adapt the program to fit different settings while maintaining fidelity to the programs core components. One exception was the component related to rapid response which was impacted by complexity at SS. This complexity can be considered through the dynamic relationship of the intervention and context including human factors and the particular set of circumstances [18]. While Couchiching and Mamaway had a program based in one location with clear escalation pathways to a clinician with an appropriate scope of practice, the SS program was split across two organizations and lack of strong linkage with the referring primary care provider which made rapid decision-making more challenging. This is in keeping with other studies which conclude that challenges integrating telemonitoring and other digital health intervention into existing workflows and organizational structures is a frequent cause of unsuccessful implementations [19–21].

Outer setting

Easy access to an eligible patient pool was a key factor that impacted rates of enrollment across the 3 sites. Community sites with defined patient lists that matched eligibility criteria were more successful at meeting targets for implementation. Pre-established heart function clinics and formalized OHT structure allowed for increased access to data regarding the CHF population in the catchment areas. This points to a clearly defined target population as a key requirement when deciding if a site is ready to initiate implementation.

The 3 sites varied across the spectrum of semi-rural to remote community settings, which was different compared to the urban tertiary setting of UHN where the program was first successfully implemented. Specific barriers in these community settings included the geographic separation between providers that limited communication if established networks and channels were not already in place. Furthermore, in more remote regions, there were considerations that were not encountered in urban centres such as weather limiting transportation access to clinics (e.g. ferry schedules in winter from the Island), or limited Wi-Fi service preventing onboarding.

Inner setting

Constructs of the CFIR’s inner setting had the strongest influences on the varying degrees of implementation success. Specifically, differences in organizational maturity contributed to the effectiveness of communication networks between individuals and organizations belonging to the respective OHTs. Strong communication channels served as facilitators while minimal previous working relationships posed significant barriers. This highlights the importance of ensuring implementation of interventions like Medly at sites with organizational maturity or ensuring adequate time for developing the necessary environment to support complex interventions such as remote patient management. Finally, access to clinical resources with HF experience was an important facilitator. Hiring an additional resource dedicated to managing patients using Medly helped avoid overburdening the staff after a certain patient threshold was reached. Although sustainability was not explicitly explored due to the timeframe of the study, these results suggest that sustainability may be greatly facilitated by shaving dedicated clinical resources to ensure ownership in onboarding patients and allowing for steady growth of the program to its maximum potential.

Implementation process

An overarching theme was the importance of time to appropriately execute the implementation strategy. Although there was agreement that the UHN team provided adequate support, they all noted that there was not enough time to meet some key milestones which were linked to funding. Sites where additional efforts to establish connections between clinicians and organizations were required experienced the most burden associated with time limitations. Having enough time for clinicians to engage early in the implementation process and learn to use digital health tools is also documented in the literature [21]. Therefore, program funders should consider the potential negative influence imposing funding-based timelines to implementation projects. Further, when faced with funding-based milestones, implementation teams should resist the urge to rush through initial phases of implementation, particularly those involving stakeholder engagement and needs assessment.

Contextual considerations for community site implementations

Based on the findings of this analysis, it was possible to identify that along with the tool itself, an appropriate patient population, an appropriate infrastructure to onboard patients, and dedicated clinician-experts were core components of this remote management program. As a result, there are several contextual considerations for the implementation of the Medly program in a community setting to enhance likelihood of success, particularly if it is occurring in a context of external time pressures (e.g. due to funding requirements). These include [1] ability to identify a target eligible patient pool for program enrollment; [2] organizational maturity with robust communication channels and established relationships among personnel and affiliated organizations; and [3] dedicated clinical resources where remote management is an explicit function in the job description. For emerging integrated care settings such as OHTs, a culture of growth and enthusiasm to help patients is a key facilitator in integrating a new system into workflow. However, not having established provider contacts can be a barrier to implementation success, particularly when there is an attempt to integrate them into later implementation stages.

Overall, even in a context with time constraints, it is important to fully execute planned strategies related to stakeholder engagements, needs assessments, and identification of barriers and facilitators as this will serve as the foundation of subsequent phases of implementation.

Limitations

Several limitations of this evaluation must be recognized. First, data for the quantitative Proctor outcomes were captured through a secondary analysis of monthly reports mandated from the provincial funders of the project. As such, rigor of the primary collection of those data is unknown and metrics reported were not specifically designed to address the proctor outcomes in this study. Second, the patient and caregiver perspective is missing from the analysis of Proctor implementation outcomes and barriers and facilitators of implementation. Although there were initial plans to interview patients, workload pressures meant that it was not feasible for local staff to contact patients and coordinate interviews with the study team as required by the Quality Improvement Review Board. Third, although the CFIR framework was used to identify implementation success and reasons for success in community settings, it did not specifically identify differences between urban and rural settings or the degree of generalizability to all rural settings. Fourth, given the duration of funding and evaluation time period for the study, it was challenging to directly assess sustainability as a metric of successful implementation of the project though parallels were drawn based on other findings. Fifth, although the small sample size does not allow us to claim that saturation was reached across all themes, our aim was to identify the most salient barriers and facilitators at each site. These key themes were consistent across sites, supporting the relevance of our findings despite the limited sample. Finally, the methods were developed based on the original CFIR framework and therefore do not include constructs from the Updated CFIR published in late 2022 [17, 22].

Conclusion

This pragmatic multiple case study evaluation demonstrated that evidence-based remote patient management programs, like Medly, can be translated from a speciality urban care setting and implemented, with fidelity, in community settings. However, to ensure implementation success, it is important to consider key contextual factors of the particular community setting as highlighted throughout this paper during the project planning phase.

Of note, given challenges with funding provided to OHTs, as of 2024, the Medly program for Heart Function was no longer in use at the Couchiching, SS, and Mamaway sites.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

HF

Heart Failure

UHN

University Health Network

TM

Telemonitoring

RM

Remote Management

OHT

Ontario Health Team

FHT

Family Health Team

BANAC

Barrie Area Native Advisory Circle

NP

Nurse Practitioner

MD

Medical Doctor

BYOD

Bring your own device

MRP

Most Responsible Physician

RN

Registered Nurse

CFIR

Consolidated Framework for Implementation Research

SS

South Simcoe

Author contributions

AD and PW planned and conceptualized the project. AD and MO collected data in the form of interviews and administrative data and performed the analysis. AD drafted the manuscript and PW, ES, HR, QP were major contributors in revising the draft. All authors read and approved the final manuscript.

Funding

Not Applicable.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This project was approved by the UHN Quality Improvement Review Committee and received Research Ethics Board exemption (QI 22–0377). Verbal informed consent was obtained from all participants prior to the interviews using a standardized script. All procedures were conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2, 2022).

Consent for publication

Not applicable.

Competing interests

ES and HR are considered inventors of the Medly system under the intellectual property policies of the UHN and may benefit from future commercialization of the technology by the UHN.