Guiding Documents for Engaging with Remote Chronic Disease Management Programs as a Healthcare Provider: A Scoping Review

Introduction: Chronic disease management programs (CDMP) that include education and exercise enhance outcomes and reduce healthcare costs. Remote CDMP have the potential to provide convenient, cost-effective, and accessible options for individuals, but it is unclear how to best implement programs that include education and exercise. This review identified and synthesized resources for implementing remote CDMP programs that incorporate education and exercise. Methods: Peer-reviewed and grey literature were systematically searched from January 1998 to May 2022. Covidence software was used for screening and extraction. The data were synthesized and presented in a narrative and tabular format. Results: Six peer-reviewed manuscripts and six grey literature documents published between 2006–2022 were included. All resources described individual programs targeting various chronic conditions. Provider training, consent, participant screening, and safety considerations were identified. Conclusions: Guidelines for remote CFMP programs are lacking. Additional work is needed to design remote CDMP guidelines incorporating education and exercise.


International Journal of Telerehabilitation
management included programs using online or website technologies, including telephone, email, applications, and videoconferencing.
The COVID-19 pandemic has resulted in increased demand for remote healthcare options to ensure that people can access care while maintaining public health safety guidelines (Portnoy et al., 2020).Previous research supports the effectiveness of remote rehabilitation in people with chronic conditions in terms of function, quality of life, satisfaction, and adherence (Seron et al., 2021).Remote formats have demonstrated good patient engagement (i.e., full participation and attendance) (Dal Bello-Haas et al., 2014) and satisfaction with services (i.e., indicated that they would participate in virtual formats again) (Harkey et al., 2020).In addition, remote formats can provide convenient, cost-effective, and accessible care options (Dal Bello-Haas et al., 2014;Harkey et al., 2020;Portnoy et al., 2020).However, there is no clear guidance for healthcare providers on how to best implement a remote program that incorporates both education and exercise to improve the self-management of chronic conditions.The objective of this scoping review is to ( 1) identify what types of documents exist for clinicians providing remote chronic disease management programs that include both educational and exercise components; and ( 2) synthesize what recommendations regarding the processes and procedures exist for clinicians implementing a remote chronic disease management program that include both education and exercise.

Methods
This review followed JBI methodology for scoping reviews (Peters et al., 2020).The a priori protocol (Van Damme & Dal Bello-Haas, 2021) is publicly available in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).This review considered primary research studies, pilot studies, and protocols with quantitative, qualitative, or mixedmethod study designs for inclusion.In addition, literature reviews and grey literature, including unpublished manuscripts, opinion papers, commentaries, organizational materials, policies, and guidelines from government sources, non-profit organizations, healthcare providers, and/or regulatory bodies, were also considered for inclusion.Documents from all countries were considered, however only Canadian regulatory bodies for healthcare providers were targeted and searched.Legislative resources were not considered for inclusion.
Inclusion criteria were as follows: (1) adults 18 years of age and older, (2) any sex or gender, (3) discussing a chronic condition, (4) explored or described chronic disease management programs comprising both education and exercise, (5) interventions were developed/provided by a licensed and regulated healthcare provider (chiropractors, physiotherapists, registered kinesiologists, registered exercise physiologists, nurses), (6) interventions were remote (i.e., synchronous and asynchronous sessions using mobile applications, web-based technologies, videoconferencing, telephone, gamification, etc., or a combination of formats).Documents that included home visits from healthcare providers were excluded.
An initial limited search of MEDLINE was conducted in consultation with a health sciences librarian to identify key articles, keywords, and index terms.Keywords and index terms were used to develop a full search strategy, which was trialed on June 6, 2021.The search strategy, including all identified keywords and index terms was adapted for CINAHL, EMBASE, AgeLine, PsycINfo, Allied and Complementary Medicine, Global Health, HealthSTAR, and Politics collection, as these databases have a focus on health, medicine, public health, public policy and the health sciences, and health services delivery.The initial search was completed on July 8, 2021, and the updated search was completed on May 9, 2022.The full search strategy for MEDLINE is provided in Table 1 below.The reference lists of the articles and other documents included in the review were screened for additional articles and resources.Only studies published in English were included due to language restrictions of the research team from 1998 to the date of the search, as telehealth was not introduced in Ontario until this time (Williams, 2012).All identified studies were uploaded into the Covidence software (www.covidence.org), and grey literature was charted into an Excel spreadsheet.Duplicates were removed and a title-abstract pilot test of 10 journal articles and 10 grey literature documents was completed to calibrate the screening process with the eligibility criteria.The remaining journal articles and grey literature sources were screened by two independent reviewers using Covidence and Excel.Full-text studies that did not meet the inclusion criteria were excluded.Disagreements between the reviewers were resolved through discussion until consensus was reached (journal articles, n=9; grey literature, n=27).
Two documents (Australian Physiotherapy Association, 2020; Pineau et al., 2006) discussed healthcare providers' prior training in remote care.One (Australian Physiotherapy Association, 2020) document described the importance of providers having familiarity with remote care, the ability to cope and manage the proposed technology, and understanding the strengths and weaknesses of remote care (Australian Physiotherapy Association, 2020).The other (Pineau et al., 2006) described the necessity of providers having adequate training prior to implementing remote programs to ensure the success of the program (Pineau et al., 2006).Both documents described the importance of remote care as equal to in-person care (Australian Physiotherapy Association, 2020; Pineau et al., 2006).One primary research article on the COPD-web (Nyberg et al., 2017) described training healthcare providers in the intervention over two sessions (Nyberg et al., 2017).The first session included information on the COPD-web, including processes and procedures (i.e., consent, outcome measures, and screening of participants), how content was supported by best practice guidelines, and how the intervention can facilitate participant selfmanagement (Nyberg et al., 2017).The second training session discussed how the providers implemented the intervention in their daily practice and reinforced the study procedures (Nyberg et al., 2017).
Three documents (Canadian Society for Exercise Physiology, 2020c; Signal et al., 2020;Zhang, 2021) described prescreening participants before remote chronic disease management for medical clearance for exercise (i.e., safe heart rate, blood pressure, medications, previous physical activity levels) (Canadian Society for Exercise Physiology, 2020c; Zhang, 2021) and safety concerns (i.e., fall risks, ability to get up off the floor, baseline mobility) (Signal et al., 2020).Medical clearance for moderate-to-high-intensity exercise was proposed to be in-person, including cardiovascular endurance, body composition, muscle strength, and flexibility (Zhang, 2021).Another document did not discuss a formal pre-screening process, but rather described the importance of identifying individuals for whom remote care may decrease delays in accessing care (Australian Physiotherapy Association, 2020).
One primary study and one document encouraged the use of motivational interviewing to improve engagement and provide education (Canadian Society for Exercise Physiology, 2020c; Reeves et al., 2021).Motivational interviews were conducted during phone calls with participants to encourage skill building, problem solving, and work toward sustained behavioural change (Reeves et al., 2021).Two other documents also identified coaching as a primary form of communication while providing education and reassurance to the participants (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020).

Primary Research Articles
Three primary research studies discussed theories on which interventions were developed (Dahlberg et al., 2016;Reeves et al., 2021;Tomkins-Lane et al., 2015).Dahlberg et al. 2016 and Tomkins-Lane et al 2015 described the use of behavioural change strategies and Reeves et al. 2021 described the use of social cognitive theory.Of the five primary research studies, four provided descriptions of action planning (Lear et al., 2021), goal setting (Lear et al., 2021;Reeves et al., 2021;Tomkins-Lane et al., 2015), self-monitoring (Lear et al., 2021;Reeves et al., 2021;Tomkins-Lane et al., 2015), problem-solving (Reeves et al., 2021), and social support (Nyberg et al., 2017;Reeves et al., 2021;Tomkins-Lane et al., 2015).Two studies used group discussion boards for participants to communicate with one another as a means of social support (Nyberg et al., 2017;Tomkins-Lane et al., 2015) and one emphasized the importance of social support within the intervention (Reeves et al., 2021).Four primary research studies were web-based interventions (Dahlberg et al., 2016;Lear et al., 2021;Nyberg et al., 2017;Tomkins-Lane et al., 2015).Three websites provided individualized packages to the participants using email (Dahlberg et al., 2016) or a unique log-in to the website forum (Lear et al., 2021;Tomkins-Lane et al., 2015).Participants were either oriented to the website by a healthcare provider via telephone in one intervention (Lear et al., 2021) or navigated through the website on their own (Nyberg et al., 2017;Tomkins-Lane et al., 2015).One primary research article used phone calls and text messages (Reeves et al., 2021).
Pedometer-based exercises have been described in three primary research studies (Nyberg et al., 2017;Reeves et al., 2021;Tomkins-Lane et al., 2015).Participants were provided with a pedometer with instructions on how to use it in two studies (Nyberg et al., 2017;Tomkins-Lane et al., 2015).Two studies described having space for participants to record their steps (Nyberg et al., 2017;Tomkins-Lane et al., 2015), and one described the option for personalized feedback on progress (Nyberg et al., 2017).One article described setting a goal of 10,000 steps for participants (Reeves et al., 2021), while another provided personalized step-goal tips on how to achieve the step goal for the day (Tomkins-Lane et al., 2015).Other exercise programs included home-based aerobic and resistance training, as described previously (Dahlberg et al., 2016;Lear et al., 2021;Reeves et al., 2021).There were several supports for the activity described, including videos that outline how to complete exercises (Dahlberg et al., 2016), information on physical activity and training techniques via websites (Nyberg et al., 2017), and walking maps of communities (Tomkins-Lane et al., 2015).

Other Documents
Establishing emergency procedures in case of an adverse event or participant deterioration was discussed in five documents (Australian Physiotherapy Association, 2020;Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Pineau et al., 2006;Signal et al., 2020).Three documents identified the need for safety plans (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Signal et al., 2020).In one document, this included identifying if someone else is in the home (while maintaining privacy), (Canadian Society for Exercise Physiology, 2020c) and in others, proactively identifying potential hazards before starting the session (Australian Physiotherapy Association, 2020; Canadian Society for Exercise Physiology, 2020c; Signal et al., 2020).Another document described obtaining participants' emergency contact information (name and phone number) and the importance of providers being able to recognize when participants should seek in-person or emergency care (Canadian Chiropractic Guideline Initiative, 2020).
Education was tailored to individual participants in three documents (Australian Physiotherapy Association, 2020;Signal et al., 2020;Zhang, 2021).One document described specific time points that education should be provided to participants, including at the time of diagnosis of the chronic condition, during annual assessments, when self-management is impacted, during exacerbation of symptoms, and during transitional care (Zhang, 2021).Other documents did not specify the time period for delivery of education (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Canadian Society for Exercise Physiology, 2020c;Pineau et al., 2006;Signal et al., 2020).Education was delivered via telephone, videoconferencing (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020; Canadian Society for Exercise Physiology, 2020c), or email (Signal et al., 2020).Telephone and/or videoconferencing education was described as coaching and included condition-specific information, selfmanagement support, physical activity advice, and status updates on participant progress (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020; Canadian Society for Exercise Physiology, 2020c).One source described emailing participants with links to additional resources that supported problemsolving, empowerment, and capacity building for self-management (Signal et al., 2020).Another resource described directing participants to other external resources to complement education, such as YouTube or mindfulness applications; however, it was not clear how these applications or specific videos were chosen (Canadian Chiropractic Guideline Initiative, 2020).
The set-up required for exercise was discussed in four documents (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Society for Exercise Physiology, 2020c;Pineau et al., 2006), and one document provided detailed guidance on the set-up for the remote exercise (Pineau et al., 2006).Space set-up requirements, such as the size of the room (10'x15'), contrasting background colour, and adequate lighting, were described in one document (Pineau et al., 2006).The technology requirements were described, including audio equipment (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Society for Exercise Physiology, 2020c;Pineau et al., 2006), camera(s) (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Society for Exercise Physiology, 2020c;Pineau et al., 2006), and a monitor (Pineau et al., 2006).One document also described the orientation of individuals toward safe participation by reviewing appropriate clothing and footwear and obtaining the necessary exercise equipment (Signal et al., 2020).
Exercise prescription was detailed in one document (Zhang, 2021) and included 150 minutes of moderate-intensity aerobic exercise per week over three days, starting with a warm-up and ending with a cool-down and relaxation exercises (Zhang, 2021).Resistance training was prescribed two-to-three times per week on non-consecutive days at moderate intensity, covering all muscle groups (Zhang, 2021).The authors also prescribed exercise one-to-three-hours after a meal (Zhang, 2021).Two other documents specified the inclusion of aerobic exercise, resistance training, and flexibility within exercise programs (Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020), and one clarified that exercise parameters were clearly communicated to the participants (Blacquiere et al., 2020).Several other documents have described the process of teaching exercises, starting with a visual demonstration by the provider, followed by an attempt by the participant with feedback (Australian Physiotherapy Association, 2020; Canadian Chiropractic Guideline Initiative, 2020; Signal et al., 2020).One document described breaking down each exercise into smaller movements for teaching purposes and progressing exercises one at a time, clarifying the starting and ending positions (Signal et al., 2020).Exercise sessions were supplemented with written or picture references (Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Signal et al., 2020) or with a recommended application (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020; Canadian Society for Exercise Physiology, 2020c).One document described following up with participants after exercise sessions with key-take-home messages to reinforce content (Signal et al., 2020).
Communication is described in four documents (Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Pineau et al., 2006;Signal et al., 2020).Effective communication has been described as integral to developing and maintaining a therapeutic relationship (Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Pineau et al., 2006;Signal et al., 2020).Recommended strategies for building a remote therapeutic relationship included demonstrating empathy (Pineau et al., 2006;Signal et al., 2020), providing validation (Blacquiere et al., 2020), acknowledging participants' experiences, emotions, and perspectives (Signal et al., 2020), and allowing for pro-social talk during sessions (Signal et al., 2020).One document acknowledged that participants were welcoming providers into their spaces at the start of the sessions (Blacquiere et al., 2020).One document also described the need for improved cueing of participants during the exercise sessions (Blacquiere et al., 2020).Nonverbal communication and active listening strategies were also described, including the use of gestures, facial expressions, and nodding (Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Signal et al., 2020).Figure 2 provides a visual representation of the study findings, summarizing the process of remote chronic disease management.

Discussion
This review identified 12 documents that provided guidance on remote chronic disease management that addressed both exercise and education.The identified documents were heterogeneous, including a variety of journal articles such as protocol studies (Nyberg et al., 2017), pilot studies (Dahlberg et al., 2016;Tomkins-Lane et al., 2015), randomized controlled studies (Lear et al., 2021;Reeves et al., 2021), consensus article (Zhang, 2021), and commentary (Signal et al., 2020), in addition to diverse presentations of grey literature guideline documents (Australian Physiotherapy Association, 2020; Blacquiere et al., 2020;Canadian Chiropractic Guideline Initiative, 2020;Canadian Society for Exercise Physiology, 2020c;Pineau et al., 2006).There were few primary research studies identified, and those identified focused on the effectiveness of the intervention rather than a larger discussion on the implementation of the interventions (Dahlberg et al., 2016;Lear et al., 2021;Nyberg et al., 2017;Reeves et al., 2021;Tomkins-Lane et al., 2015).While the focus on effectiveness is unsurprising, as it aligned with the stated research objectives of the respective studies, it highlights an implementation science gap within the literature on remote care.Relatively few other documents were identified, and it is surprising that many regulatory bodies and professional organizations provided limited guidance on implementing remote education and exercises.
Several studies within this review utilized pedometer-based walking programs as exercise components (Nyberg et al., 2017;Reeves et al., 2021;Tomkins-Lane et al., 2015).Walking is an accessible, low-risk activity with substantial health benefits for individuals with chronic conditions (Lee & Buchner, 2008).However, walking alone does not fully align with the recently published 24-hour movement guidelines from the Canadian Society for Exercise Physiology (CSEP) (Canadian Society for Exercise Physiology, 2020b, 2020a), which advocates for the inclusion of aerobic and resistance training of all major muscle groups, flexibility, and range of motion exercises (Canadian Society for Exercise Physiology, 2020a, 2020b).Other documents describe exercises with progressions and regressions to accommodate various abilities (Dahlberg et al., 2016;Signal et al., 2020).Having resources that outline variations of exercises helps manage symptom fluctuations that are expected when living with a chronic disease (Wagner et al., 2022).
All documents within this review targeted one-on-one healthcare provider-participant interactions, a missed opportunity for creating remote peer support communities to support self-management.The eHealth Enhanced Chronic Care Model (eCCM), derived from the widely accepted care model for managing chronic diseases, identifies that virtual communities can provide support to participants and result in more engaged, informed, and confident individuals who can better manage their chronic conditions (Gee et al., 2015).The role of peer support in diabetes management was examined qualitatively, with participants indicating favorable outcomes, including better engagement, information provision, self-monitoring, action planning, and goal prioritization because of group sessions (Borek et al., 2019).However, given the lack of guidance on how to implement group remote chronic disease management, more evidence is needed to support clinicians in implementing group programs online.
Several documents included in this review identified the importance of enhanced communication abilities among clinicians providing remote care, with two specifying motivational interviewing as an effective method.Motivational interviewing is a technique that seeks to resolve the uncertainty often experienced by individuals seeking change by focusing on communication with participants regarding the desired change (Purath et al., 2014).Focusing on the desired change during conversations can help participants understand their personal motivations for wanting to change and develop more effective goals and action plans (Purath et al., 2014).In a remote program, motivational interviewing can help identify barriers, beliefs, motivations, and emotions (Purath et al., 2014) regarding participation virtually and provide space for collaboration to develop action plans that are both valued and achievable by the participant.Motivational interviewing is a skill that becomes more effective with formal training (Purath et al., 2014), and clinicians aiming to implement virtual care would benefit from seeking training opportunities.
Although remote chronic disease management programs may help increase access to care for some individuals, it is important to acknowledge that they are not without limitations.Videoconferencing requires resources that are inaccessible in all contexts.Adequate Internet services are not available in 'digitally isolated regions', as in certain rural and remote communities, and further perpetuate health disparities already experienced in these locations (Hirko et al., 2020).The cost of devices (i.e., tablets, laptops, and smartphones) necessary to participate in virtual programs is high and may make virtual programs inaccessible, as chronic disease disproportionately impacts those with lower socioeconomic status (Public Health Agency of Canada, 2020).For remote programs to be impactful for communities without specialized clinicians, significant work is needed to improve access to reliable internet (Hirko et al., 2020), and resources to access the technology are necessary.
A policy review of the legislation may be beneficial for understanding the legalities of providing remote care from a privacy and confidentiality perspective as well as funding and billing perspectives.A more detailed review of the Canadian regulatory bodies' position on remote care may also allow for clarification of the current roles and responsibilities, while highlighting any changes that may need to be advocated to facilitate better access to remote chronic disease management programs.For example, healthcare providers must be in the same province or territory at the time of care in Canada to provide care virtually International Journal of Telerehabilitation

Strengths
This review has strengths in the methodology used to identify, map, and synthesize available evidence.Numerous databases were searched in addition to grey literature sources (targeted websites, Google, CADTH grey literature database, and Canadian Politics Collection).The systematic search was completed in July 2021 and was updated in May 2022.The dates of the review coincided with the move to remote programs in response to the COVID-19 pandemic.Two reviewers were used at each stage of the scoping review in alignment with best practices.

Limitations
Due to our inclusion criteria, studies that provided guidance on virtual education or virtual exercise only were excluded.However, given the importance of both education and exercise, authors chose to focus only on documents that included both components.Existing reviews exist on remote chronic disease education (Warsi et al., n.d.) and exercises (Brown et al., 2022).Reviews of education alone have demonstrated that virtual education and social support produce similar outcomes to in-person education (i.e., improved mental health, accessibility to care, development of health knowledge, and skills) (Banbury et al., 2018;Warsi et al., n.d.).Similarly, reviews on exercise alone are also available that demonstrate the feasibility of virtual or remote exercise with improvements in exercise capacity and quality of life (Brown et al., 2022).Primary research studies comparing remote programs to in-person (i.e., the comparison group was in-person) were excluded from the review, and these studies might have provided information on how to implement remote programs.
Only licensed professionals were included in this review, which may have limited our results.Some researchers may have trained research assistants or utilized personal trainers and other unregulated providers to deliver the remote program.Only documents published in English were included because of language and resource limitations of the research team.

Conclusions
Remote chronic disease management programs, including exercise and education, have the potential to improve access to care.However, there is limited guidance and research available on how to implement a remote chronic disease management program that incorporates both education and exercise and is delivered by a registered health care professional.Current guidelines focus on one-on-one care, which may limit the impact of virtual group programmes and communities on chronic disease management.

Table 1
MEDLINESearch Strategy Completed July 8, 2021 (Virtual or telerehabilitation or telehealth or mHealth or eHealth or remote or video*).mp.[mp=title, abstract, original title, name of substance word, subject heading word, floating sub-* or recommend* or policy or regulation* or principle*).mp.[mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]