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An Evaluation of the Structure of an Integrated Regional Remote Care Management Program for Patients with Selected Chronic Diseases in Canada Cover

An Evaluation of the Structure of an Integrated Regional Remote Care Management Program for Patients with Selected Chronic Diseases in Canada

International Journal of Integrated Care
Volume 26 (2026): Issue 1
By: Diedron Lewis,  Karin Swift and  Sarah Weberman  
Open Access
|Feb 2026
Figures & tables

Figures & Tables

Table 1

Updated Rubric for evaluating RCM domains and characteristics.

DOMAINS/CHARACTERISTICSHIGH (3)MODERATE (2)LOW (1/0)
Domain A: Technology
A1. Alert protocol[Automatic][Manual][None] or [Unknown]
A2. Data entry modality[Fully automated][Semi-automated][Manual] or [Unknown] or [None]
A3. Data access[Centralized][Fragmented][None] or [Unknown]
A4. Manual data entry (frequency)[Monthly][Weekly] or [Bi-weekly][Daily] or [Unknown] or [None]
Domain B: Touch
B1. Follow-up communication[Synchronous on demand][Asynchronous on demand][Pre-scheduled] or [None] or [Unknown]
B2. Level of monitoring specialization[Moderately to highly specialized][Low specialization][No specialization] or [None] or [Not applicable]
B3. Availability of team[24/7] or [Regular + weekends][Regular workdays][Irregular] or [None] or [Not applicable] or [Unknown
B4. Risk profile[High][Moderate][Low] or [Non-specific] or [Unknown]
Domain C: Integration
C1. Integration consideration

  • Services and resources

  • Workflows

  • Systems and infrastructure

[All three features][Any two features][0–1 feature] or [Unknown]
C2. Device linkages[Multiple linked] or [Single][Multiple separate][None] or [Unknown]
Domain D: Equity/Patient-Centricity
D1. Device ownership[System provided][Mixed ownership][BYOD] or [None] or [Unknown]
D2. Equity consideration

  • Language inclusivity

  • Digital literacy

  • Offline functionality

  • Cultural adaptability

  • Digital access

  • Access to health information

[5–6 features][3–4 features][1–2 features] or [None] or [Unknown]

[i] Source: Centre for Digital Health Evaluation, Women’s College Hospital Institute for Health System Solutions and Virtual Care (2023) “Remote Patient Monitoring: Evaluation Final Report” and authors’ input.

Table 2

Updated RCM taxonomy matrix according to type and group.

GROUP
GROUP AGROUP BGROUP CGROUP DGROUP EGROUP FGROUP GGROUP HGROUP I
TECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCH
HighHighHighHighHighHigh
ModModModModModMod
LowLowLowLowLowLow
TYPEType 1
IntegrationEquity1A1B1C1D1E1F1G1H1I
HighHigh
Type 2
IntegrationEquity2A2B2C2D2E2F2G2H2I
High
Mod
Type 3
IntegrationEquity3A3B3C3D3E3F3G3H3I
High
Mod
Type 4
IntegrationEquity4A4B4C4D4E4F4G4H4I
ModMod
Type 5
IntegrationEquity5A5B5C5D5E5F5G5H5I
High
Low
Type 6
IntegrationEquity6A6B6C6D6E6F6G6H6I
High
Low
Type 7
IntegrationEquity7A7B7C7D7E7F7G7H7I
Mod
Low
Type 8
IntegrationEquity8A8B8C8D8E8F8G8H8I
Mod
Low
Type 9
IntegrationEquity9A9B9C9D9E9F9G9H9I
LowLow

[i] Source: Centre for Digital Health Evaluation, Women’s College Hospital Institute for Health System Solutions and Virtual Care (2023) “Remote Patient Monitoring: Evaluation Final Report” and authors’ input.

Table 3

Chronic diseases RCM program features based on the RCM taxonomy characteristics.

CHARACTERISTICSOPERATIONAL DEFINITION
A1: Alert protocol[Automatic]
An alert is triggered when at least one recorded vital sign of a patient deviates from an established range.
A2: Data entry modality[Fully automated]
The tablet and all instruments used to measure vital signs are Bluetooth-enabled, and measurements are recorded electronically.
A3: Data access[Centralized]
Recorded measurements/collected data are managed by the software vendor and are accessible to the RCM monitoring team and patient.
A4: Manual data entry (frequency)[Optional]
Patients have the option to enter their vital signs measurements manually. This is not a requirement since the devices that they receive are Bluetooth-enabled, and measurements are recorded electronically. They also have the option to contact the RCM team via call or text using the software to report changes in symptoms if needed.
B1: Follow-up communication[Synchronous & Asynchronous on demand]
Patients have the option to contact the RCM team via call or text using the software to report changes in symptoms as needed. However, the RCM team is only available Monday to Friday between 9:00 am and 5:00 pm. Patients have the option to access other community resources outside of this time. Messages left for the RCM team outside of working hours are addressed on the next business day.
B2: Level of monitoring specialization[Highly specialized]
The core RCM monitoring team includes a physician, a rapid response nurse, nurses, paramedics, and respiratory therapists.
B3: Availability of RCM team[Regular workdays]
The RCM team is available Monday through Friday, 9:00 am to 5:00 pm. Patients have the option to access other community resources outside of this time.
B4: Risk profile[Inclusive]
There is no restriction on the severity of disease status for enrolment in the RCM program. However, the patient or their caregiver must be able to measure vital signs.
C1: Integration considerationsThe RCM program is integrated with the following:

  • Existing services and resources (i.e., shared full-time equivalent with existing services and programs) ☑

  • Existing workflows (e.g., embedded into usual clinical visits and procedures such as intake processes) ☑

  • Existing systems and infrastructure (e.g., patient records, EMRs, etc.) ☑

C2: Device linkages[Single]
The remote monitoring software is provided by a single vendor that is compatible with a single tablet manufacturer.
D1: Device ownership[System provided]
Patients are provided with all devices (including a tablet, pulse oximeter, blood pressure cuff, weight scale (for patients with CHF) and a SIM card if required) in a single package.
D2: Equity considerationThe RCM program promotes equity by:

  • Promoting language inclusivity: The program is accessible in seven languages ☑

  • Promoting digital literacy (provides regular support to users with little education or digital literacy) ☑

  • Enabling offline functionality (does not require users to have constant internet access and/or allows data to be collected offline and synced at a later time) ☑

  • Adapting the program culturally (reports any considerations in making the RCM platform/program responsive to culture) ☒

  • Providing patients with digital access (provides all devices to the user and/or does not make the user possess a specific device or access to the internet as a pre-enrolment requirement) ☑

  • Enabling patients’ access to their own personal health information (interface allows patients to see their own data) ☑

Table 4

CCHOHT chronic diseases RCM program scores using the OMH updated rubric.

DOMAINS/CHARACTERISTICSHIGH (3)MODERATE (2)LOW (1/0)TOTALAVERAGE
Domain A: Technology
A1. Alert protocol33
A2. Data entry modality33
A3. Data access33
A4. Manual data entry (frequency)33
Domain B: Touch123
B1. Follow-up communication22
B2. Level of monitoring specialization33
B3. Availability of team22
B4. Risk profile33
Domain C: Integration102.5
C1. Integration consideration33
C2. Device linkages33
Domain D: Equity/Patient Centricity63
D1. Device ownership33
D2. Equity consideration33
62.5
342.875
Table 5

Updated OMH RCM taxonomy matrix according to type and group for CCHOHT chronic diseases RCM program.

GROUP
GROUP AGROUP BGROUP CGROUP DGROUP EGROUP FGROUP GGROUP HGROUP I
TECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCHTECHTOUCH
HighHighHighHighHighHigh
ModModModModModMod
LowLowLowLowLowLow
TYPEType 1
IntegrationEquity1A1B1C1D1E1F1G1H1I
HighHigh
Type 2
IntegrationEquity2A2B2C2D2E2F2G2H2I
High
Mod
Type 3
IntegrationEquity3A3B3C3D3E3F3G3H3I
High
Mod
Type 4
IntegrationEquity4A4B4C4D4E4F4G4H4I
ModMod
Type 5
IntegrationEquity5A5B5C5D5E5F5G5H5I
High
Low
Type 6
IntegrationEquity6A6B6C6D6E6F6G6H6I
High
Low
Type 7
IntegrationEquity7A7B7C7D7E7F7G7H7I
Mod
Low
Type 8
IntegrationEquity8A8B8C8D8E8F8G8H8I
Mod
Low
Type 9
IntegrationEquity9A9B9C9D9E9F9G9H9I
LowLow
DOI: https://doi.org/10.5334/ijic.8629 | Journal eISSN: 1568-4156
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Language: English
Submitted on: Mar 15, 2024
Accepted on: Jan 19, 2026
Published on: Feb 5, 2026
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
remote care management,
program evaluation,
digital health

© 2026 Diedron Lewis, Karin Swift, Sarah Weberman, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 26 (2026): Issue 1
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