Implementation science is defined as the scientific study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners. Failure of implementation is more common in resource-limited settings and may contribute to health disparities between rural and urban communities. In this pre-implementation study, we aimed to (1) evaluate barriers and facilitators for implementation of guideline-concordant healthcare services for cancer patients in rural communities in Upstate New York and (2) identify key strategies for successful implementation of cancer services and supportive programs in resource-poor settings.n = 43, survey n = 120). Information was collected using both in-person and web-based approaches and assessed attitude and preferences for various models of cancer care organization and delivery in rural communities. Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Data was analyzed using grounded theory.The mixed methods study was guided by the Consolidated Framework for Implementation Research (CFIR). Using engagement approaches from Community-Based Participatory Research, we collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship services (three focus groups, Responders reported preferences for cross-region team-based cancer care delivery and emphasized the importance of connecting local providers with cancer care networks and multidisciplinary teams at large urban cancer centers. The main reported barriers to rural cancer program implementation included regional variation in infrastructure and services delivery practices, inadequate number of providers/specialists, lack of integration among oncology, primary care and supportive services within the regions, and misalignment between clinical guideline recommendations and current reimbursement policies.Our findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant healthcare services for cancer patients in rural communities. One strategy to overcome these barriers is to improve provider cross-region collaboration and care coordination by means of teamwork and facilitation. Augmenting implementation framework with provider team-building strategies across and within regions could improve rural provider confidence and performance, minimize chances of implementation failure, and improve continuity of care for cancer patients living in rural areas. The rural-urban gap in cancer outcomes continues to expand despite overall improvement in cancer screening and advances in cancer treatments , 2. RuraGuideline-concordant multidisciplinary team-based cancer care is defined as the cooperation between different specialized professionals involved in cancer care with the overarching goal of improving treatment efficiency and patient care . ExampleIn the last 20 years, many new clinical and public health programs have been developed to improve quality and continuity of care for geographically isolated populations; however the impact of these programs has been mixed . ExampleGuided by the Consolidated Framework for Implementation Research (CFIR), this pre-implementation study aimed to identify specific barriers and facilitators to implementing guideline-concordant multidisciplinary cancer services in rural communities of Upstate New York and propose targeted evidence-based implementation strategies consistent with our findings . The CFIThis study was conducted as a part of the pre- implementation phases of a community engagement initiative entitled “Virtual Rural Oncology Community” (V-ROC) –29. The n = 5) from one rural county (phase I). The key informants  worked together with the study team to identify and recruit a broader patient and provider participants panel from the same county  using snowball approach . Correspondingly, written informed consent from participants was not required to participate in this study.intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation), which are subsequently detailed into over 30 different constructs, or “sub-domains” that could serve as implementation barriers or facilitators. Where appropriate, we used publicly available data to assess relevant CFIR constructs  were guided by the Consolidated Framework for Implementation Research (CFIR)  to identnstructs   to include in the purposeful sampling for the qualitative data collection. The CFIR also guided the choice of themes/questions for the data collection addressing inner and outer settings and processes guiding decisions about cancer care delivery in rural settings. We used grounded theory method to then generate a process theory about rural cancer program implementation generated from the analysis of the data –46.Interviews were recorded and transcribed by the study coordinator and analyzed and interpreted by the V-ROC team. Four team members analyzed the data by using NVivo software  to perfoWe first collected qualitative data through focus groups with rural cancer care stakeholders to identify the most relevant factors and parameters affecting care delivery, planning and decision-making about cancer treatment and cancer programs implementation in the region. We used concurrent data generation and/or data collection and analysis so that results from the previous focus group were immediately incorporated in the discussion guide for the subsequent focus groups. We applied constant comparative analysis and iterative process to progress from the initial to intermediate to advanced  coding.n = 12, 90 min duration) that included physicians, nurses, cancer patients, and their caregivers. The participants were selected from the list of regional experts in oncology and rural primary care who have previously collaborated with the university medical center. The ThinkTank collaborative software . These focus groups were conducted during monthly regional care coordination committee meetings in one of the rural counties. All committee members were invited to participate in the focus groups, none refused.We conducted three focus groups, that included 43 participants and lasted 2 h 20 min total. The focus groups explored stakeholder values and preferences regarding disease and disability, attitude toward medical innovation, knowledge about cancer and cancer treatment, and resource availability that may distinguish care delivery, planning and decision-making about cancer treatment in rural vs. urban areas. Group 1 was a virtual cross-disciplinary focus group (software  was usedn = 5) was determined using purposive sampling to further probe for sensitive or ambiguous themes that came up during the focus groups . Interview questions were informed by the CFIR and focus group findings, but also included open-ended questions to encourage unbiased opinions  and paper questionnaires (groups 2–3) from all participants. In addition, the surveys were distributed to rural patients and caregivers at community free meal events . The questionnaires were based on the set of questions and priorities identified by the participants of focus group 1 and project key informants. Finally, we integrated both qualitative and quantitative findings by presenting the findings to a sub-group of rural stakeholders and discussing validity and possible interpretations of the findings .“Nurse would often triage a message and may well answer the patient's concern best, and fastest [compared to a physician]” (s6).Participants also pointed out to a frequent discordance between provider's administrative titles  and their roles on patient care teams . Both patients and providers identified this lack of clear roles and “rode maps” as an additional challenge for patients trying to identify and navigate available resources.One factor on which different stakeholders disagreed was the effect of provider reimbursement approach and practice organization on feasibility and effectiveness of cross-institutional cancer care teams. Providers who had experience working for large regional systems and in salaried environments were more optimistic about cross-institutional collaboration than individuals who worked in a fee-for-service solo provider environment.“[Provider-to provider communication takes time and] needs to be incorporated into physician schedule—not something to be done between appointments. Quality metrics based on use [of teamwork] should also be tied into evaluation of physician performance” (s2).“Reimbursement for physician time spent doing this important aspect of care (communicating and coordinating) is a real barrier” (m2).All stakeholders were open to using innovative health IT and telemedicine solutions to facilitate cross-regional care. However, no rural healthcare provider expressed confidence that adequate resources were available to meet patients' needs in rural settings .“[Patient with] complex needs will often benefit from care manager input, so seems essential these persons would use [regional EMR application]” (s6).However, both providers and patients pointed out to several barriers that may compromise quality and access to virtual cancer care in rural communities.“Unreliable technology is often the main reason why people don't even try (communicating and coordinating)” (s6).“Many patients don't have access to computer and computer literacy to make advantage of (remote communication with providers)” (p1).“It sounds good in theory but what about technologic challenges for those not accustomed to this type of communication” (s6).A number of concerns regarding variation in health insurance coverage, resources availability, supportive services, and professional expertise were also raised.Participant responses revealed that organizational and individual capacity to support new program implementation varied by county and depended on other initiatives and challenges the stakeholders were facing at the time, including the role of opinion leaders , access to knowledge and information, available resources, relative priority, learning climate, as well as how the innovation was perceived by the key stakeholders in terms of the relative advantage it could provide, its complexity and costs.“You need champions and advocates who will have true credibility—i.e., surgeons for other surgeons, GPs for other GPs, RNs for other RNs, etc.” (m2).“Reimbursement for time spent in this work” (s6) were perceived extremely important both to demonstrate institutional commitment for innovation and to remove financial barriers for implementation that is significant for small rural practices with limited staff.Respondents were also emphasized that non-financial incentives could be very effective for stimulating teamwork and cooperation including “patient satisfaction metrics” (s6) and “success stories from early adopters” (s6). From patient point of view, provider communication and encouragement were by far the most important motivation to adhere to new care protocols. As one patient put it “Definitely talk up advantages [of multidisciplinary care referrals] while patients are in for appointments with the medical team” (p2).Reported threats to implementation of any new program included hospital, practices, and health systems mergers that could disrupt existing formal and informal networks and provider teams. Regional economic stability  and public health threats  redirected regional resources and stakeholder attention from what was perceived as low acuity problems . The summary of county resources and infrastructure in presented in Survey results demonstrated that while some rural healthcare providers emphasized the importance of local delivery of cancer services (28%), many more were open to regional cancer networks (72%) as long as their patients were appropriately supported locally . Most paWhile distance to care was ranked as the most important barrier for access to regional cancer services, financial burden and lack of awareness about cancer treatment guidelines and local treatment options and resources were also important obstacles .Respondents favored in-person, one-on-one care coordination such as patient navigators (average rank 1.5/5) or county care coordinators/managers (1.9/5) higher than telemedicine (3.3/5) and visiting practice facilitators (3.3/5) .Current cancer care guidelines recommend cancer care that is multidisciplinary and collaborative, including cross-institutional and provider-to-provider collaborations , 17, 51.Informal teams and teamwork have a long history in healthcare because they are an intuitive solution to care fragmentation, provider information burden and increasing specialization of medical care –59. OrgaEven with our small sample size in this pilot study, we identified three thematic structural dimensions affecting implementation of a guideline-concordant multidisciplinary cancer care programs in rural communities. These dimensions include (1) lack of integration among oncology, cancer supportive and primary care services within and across rural counties, (2) misalignment between clinical guideline recommendations and health insurance reimbursement and provider payment policies, and (3) regional variation in infrastructure and workforce availability that makes standard protocols difficult to follow.Based on our findings, below we propose several strategies for planning and implementation of multidisciplinary cancer services programs in resource-poor communities that could facilitate adaptation of academic care delivery models for rural communities .Salas and colleagues demonstrated that team's efficiency depends on how well team members perform across seven specific domains of teamwork—team knowledge and attitude, cooperation, coordination, communication, cognition, coaching (feedback and monitoring) and identifying supportive conditions  , 68–73. Unlike many in-hospital or larger clinic-based teams where teamwork is dependent on face-to-face interaction, stakeholders in our study frequently described teams that consisted of several health providers who have never met face-to-face and were only connected through shared patients. Members of such “regional teams” often further separated by organizational boundaries, geographic distance, health insurance coverage , information systems, and privacy constraints .Recent studies in cancer and other fields have provided evidence that quality care depends upon timely information exchanges and regular communication flow between all those stakeholders involved in treatment  –76. RemoMultidisciplinary team-based models of cancer care delivery  were originally developed and implemented in large academic medical centers , 81. LarAn additional challenge is that many supportive and highly effective cancer services that are in high demand among cancer patients are not billable or nor reimbursed by many health plans  . FinallyAt large cancer centers, non-billable staff efforts could often be covered through other cost-sharing mechanisms, such as research, training or administration. In small rural clinics, funding opportunities for health providers are limited to billable services. Therefore, without a reimbursement model directly aligned with the realities of providing multidisciplinary integrated cancer care, such care is prohibitively expensive and unsustainable in rural settings.Our findings and prior research demonstrate that provider availability and care delivery patterns vary greatly among the rural counties . We obseThe noteworthy strength of this study is its ability to collect information from a wide range of stakeholders, both rural and urban, cancer specialist and non-specialists, clinicians, and informal caregivers. As reported previously, recruitment of rural, low socio-economic status participants to studies can be time-consuming and challenging . MoreoveIn summary, our findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant cancer care services in rural settings. One strategy to overcome these barriers is to improve provider cross-region communication and care coordination by means of team training and facilitation. Augmenting implementation planning with provider team-building strategies across and within regions could minimize implementation failure improve implementation efficiency, stakeholder buy-in, sustainability of guideline-concordant models of cancer care delivery, and continuity of care for cancer patients living in rural areas. Further research is needed to evaluate the effectiveness and cost-effectiveness of teamwork training and approaches as an implementation strategy in rural regions and other settings with limited specialist workforce availability.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The University at Buffalo Institutional Review Board reviewed the study and made a Not Human Research determination because the study questions were focused on healthcare system and services delivery, not participant's health (UB IRB STUDY00004348). These accommodations were recommended by the study community champions to improve subject participation.CC-I analyzed the study data, contributed to study conception, and interpreted the study results. NS, LC, and KN provided critical review, contributed to study conception, and interpretation. KN secured funding for the Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award (2481-UB-IC E.N). PB contributed to study conceptualization, data collection, and manuscript preparation. FF, DH, IR, JR, LC, MS, and NT guided the development of stakeholder engagement plan and assisted with building the research network. KT helped identify IT platforms for the study data collection and developed the online patient and provider portal. All authors reviewed the paper, provided feedback on earlier drafts, and approved the final manuscript.This work was funded by a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award (2481-UB-IC E.N.). NS's research was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College Hospital NHS Foundation Trust. NS was a member of King's Improvement Science, which offers co-funding to the NIHR ARC South London. Its work was funded by King's Health Partners , Guy's and St Thomas' Charity, and the Maudsley Charity.The views expressed in this publication are those of the authors and not necessarily those of the NIHR, the ESRC or the Department of Health and Social Care.NS is the director of the London Safety and Training Solutions Ltd., which offers training in patient safety, implementation solutions, and human factors to healthcare organizations. LC reports royalties from UpToDate, Springer, Wolters-Kluwer, grant support from University of Alabama for Children's Oncology Survivorship Guidelines; all outside the submitted work. CC-I owns shares of Fortive Corporation and Danaher Corporation, outside of the submitted work. IR was employed by Mid-Atlantic Permanente Medical Group. NT was employed by Flatiron Healthcare Inc. KT was employed by KJT Group. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potentialconflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The population needing health care services grows faster than the management capabilities of our current health care delivery models. Patients journeying through our current health care systems receive a spectrum of services, often imperfectly matched to medical needs. We describe a framework of the Digital Care Horizon to accelerate digital transformation from the perspective of a health care delivery system. We describe service delivery models across the horizon, discuss potential challenges and partnerships to facilitate the digital extension of health care, and mention concepts beyond the current horizon. Digital health encompasses technology-enabled services to advance patient health and well-being. Digital health includes the following: (1) telemedicine and telehealth, enabling patient and health care provider engagement through telephone and video; (2) digital tools, monitoring, aggregating, and sharing patient data with health care providers; (3) mobile health , allowing patient access to health care information and expertise through applications for smartphones and tablets; and (4) health information technology, empowering providers to use algorithms and electronic health records (EHRs) to identify, order, and deliver health care services. Digital health has the potential to improve access to health information and expertise, permitting patients health care customization, cost reduction, and the opportunity to have access to omnichannel experiences that meet their medical and social needs.1 Patients increasingly access digitally enabled health care from their homes and on their mobile devices. New technologies and services create opportunity for medical expertise existing in traditional health care institutions to be disseminated through the new digital frontier and within multiple avenues of care delivery. However, traditional health care organizations may be challenged with ideation, creation, and execution of these digital transformations.Within our traditional health care system, patients receive a spectrum of services from incomplete care to overmedicalization, often imperfectly matched to their true needs.We describe a framework to guide digital transformation through the extension of health care services beyond traditional care settings. We propose the “digital care horizon”  with cen2 These models foster connection between people, allow for medical examinations and procedures, and are the most enabled by current payment models. Current face-to-face models can be enhanced through virtual interactions, informed by the remote collection of data outside of the office visit, and augmented through new technologies such as augmented, virtual, and mixed reality to aid in learning and healing, thereby extending the care episode beyond traditional appointments and outside of the current capabilities.Traditionally, health care systems have been based on face-to-face models of care whereby clinical team members  have scheduled visits (in the outpatient setting) or interactions  in shared physical spaces.3 Information is also requested regarding their social determinants of health. Our clinical teams use this information to understand the environment from which a patient arrives and to arrange for nonmedical services.4 Once an episode of care is completed on site, our care teams also digitally extend patient support into the postvisit space through nurse-led individual and group educational programming.3 These models extend the “episode of care” beyond the face-to-face visit advancing understanding of patient need, increasing visit efficiency, and supporting the patient through their medical journeys.We have digitally extended our face-to-face models into the spaces before and after patient visits. When patients first approach care at one of our campus locations, they are requested to provide information on previous diagnoses, procedures, and images and on their goals of care. This information is used by allied health and nursing to arrange itineraries for on-site visits and to determine whether a patient may benefit from a virtual previsit.5 Many brick-and-mortar practices transitioned care processes to virtual interactions in the face of declining face-to-face appointments and the need to safeguard against COVID-19 transmission.6 From 2019 to 2021, the use of telemedicine for office-based physicians increased from 15% to 86%. In 2021, 91% of primary care physicians, 87% of medical specialty physicians, and 75% of surgical specialty physicians used telemedicine.7 To expedite the awareness and adoption of digital care, the US Department of Health and Human Services facilitated changes by reimbursing digital interactions at parity with face-to-face interactions. Early in the pandemic, telemedicine was driven by interests to reduce viral transmission; currently, the use of telemedicine is driven by access.8 Nationally, workforce shortages in rural settings outpace those in urban settings,11 creating a distinct need for new models of care for medically complex patients in rural settings.The coronavirus disease-2019 (COVID-19) pandemic, declared as a public health emergency in March 2020, accelerated the digital transformation of health care.12 initiative. Through PEARL, launched in Rochester and expanded to rural hospital sites, advanced practice providers conduct a video visit 2–5 days postdischarge and review new and long-term medications, self-management plans, and home supports. Patients reported benefitting from the video visit (agree: 77.3%), expressed interest in future video visits (agree: 70.0%), and would recommend video visits to friends or family (agree: 82.3%). As more patients and practices adapt to the use of telemedicine initiatives, it will be important to provide seamless care outside traditional brick-and-mortar structures.Within our rural-serving primary care practices, we have virtually empaneled a large population of patients with the highest medical need. We deployed clinical workflows for 2 types of visits to provide telecare: (1) clinic to home and (2) clinic to clinic. With the patient in the rural clinic and the provider at a remote site with video connection through the EHR, we can obtain nurse-acquired vitals along with radiology and laboratory testing to support diagnosis and management. For this type of management to be sustainable and ensure a high level of safety, we have also introduced advanced remote diagnostics tools. From a hospital perspective, digital tools have been used to facilitate postdischarge transition of care through the Postdischarge Early Assessment with Remote video Link (PEARL)13 Remote monitoring, the expansion of telemonitoring capabilities into patient environments, includes continuous sensors, wearable and handheld devices, and implanted medical devices. The mix of passive and active data collection, linked to care teams able to respond immediately to patient need, expands the reach of medical practices directly into spaces where patients reside. Telemonitoring has been associated with reduced mortality and improved disease self-management.14Telemonitoring is a broad category including ongoing collection of vital information as a measure of patient status.15 To serve patients with serious and complex medical needs, we developed the Remote Monitoring to Enhance Timely Hospital Dismissal (REMODi) program in partnership with the Department of Nursing and Center for Digital Health.16 This program has enrolled episode-based remote monitoring programs for patients with serious and complex conditions, such as cirrhosis and acute kidney injury, and for patients undergoing life-altering operation through pancreatectomy, who are leaving the hospital. Patients are monitored by virtual-first nursing staff who are skilled in remote patient monitoring, with workflows enabling escalation into our specialty nursing and provider teams to instantly connect patients with the expertise needed. Telemonitoring solutions allow care teams to extend health care services into patient residential settings, allowing for healing in environments more comfortable for patients and caregivers.Mayo Clinic Center for Digital Health has enabled a technology framework allowing embedded decision trees and advanced logic to drive nursing teams to monitor and respond to remote monitoring sensors outside the walls of health care facilities.17 Business sector evolution of self-management, such as automated teller machines and airline booking18 have heightened patient expectations of health care services.19 Facilitated self-care in health care empowers patients and caregivers to manage health-related tasks with the assistance of digital guidance and feedback; several examples are currently available in the iOS and Android application stores.18 Current tools enable weight reduction and management, sleep monitoring and feedback, and well-being activities such as guided meditation and resilience training. Barriers to self-care among patients experiencing complex medical conditions include lack of self-care knowledge and lack of confidence in aspects of self-care, difficulty in making and maintaining lifestyle change(s), and lack of social and health care provider support for self-care.21 Current technological capabilities are able to help patients build self-efficacy and knowledge regarding their condition, can use aspects of motivational theories to encourage lifestyle change, and can provide peer support and linkage to members of the health care team to facilitate self-care. Provider-directed facilitated self-care products are currently limited but would offer advantages of protocols developed by clinical experts for complex medical conditions and linkage to clinical teams.Health has been defined as “the ability to adapt and self-manage in the face of social, physical, and emotional challenges.”23 Care plans are enabling self-care of survivors of breast cancer to monitor for suggestion of recurrence, prepare for colonoscopy, and manage chronic migraine through medications and lifestyle. Pilot studies of a program established for chronic insomnia disorder observed favorable patient engagement and program efficacy.23 Patient-centered research underpinned the following key design principles driving the creation of our facilitated self-care tools: (1) responsive with customized goals, treatment strategies, and level of interaction; (2) personalized to patient input to support engagement; and (3) knowledgeable about the clinical course and management of medical conditions to drive applicable content accessible “just-in-time.” Facilitating self-care through digital tools will allow clinical teams to extend medical expertise to moments when patients need them the most and within a format that meets patient needs.To enable health self-management and to aid procedural preparation, Mayo Clinic has developed interactive medical care plans leveraging medical expertise translated into digitally delivered clinical workflows.24 continues to evolve as technology advances and patient expectations change. Extension of care from health care systems to population health models through digital enablement creates opportunities to disseminate evidence-based expertise and to facilitate screening for serious and complex medical conditions. The availability of continuous interconnection through current technologies, such as social media, enables easier communication with patients.25 Communication across these media create awareness, affirmation, and support, which has been traditionally hard to achieve in several patients.26 With the involvement of institutions continuously generating scientific evidence, electronic educational campaigns can be leveraged as a dissemination strategy. In addition, through incentivization within the American Recovery and Reinvestment Act (2009), many health care organizations have adopted EHRs as a primary source of medical documentation. The digitization of these medical records can be leveraged to screen large amounts of patients to schedule routine preventive tasks, to identify those who may most benefit from clinical intervention, and to “push” diagnostic testing directly to a patient’s home.Population health management, or the oversight of populations of people and their health outcomes, such as the identification of individuals in need of social and medical services,16 These resources are available within our EHR and are made available to >50 new patients a week. Mayo Clinic has also leveraged the EHR to screen patients at risk for poor outcomes related to COVID-19 to receive monoclonal antibody therapy27 and for patients with specific diagnoses in need laboratory testing, such as hypertensive patients receiving angiotensin-converting enzyme inhibitors or diuretics who need renal function and electrolyte testing. Health care organizations have an integral role in managing population health, creating accessible information to be used at scale and leveraging tools to identify and connect with patients requiring health care services.Patients with serious and complex medical conditions often struggle to identify reliable health information. To provide patients with a single place to warehouse reliable health information, our clinical teams have created evidence-based guidance within a web-based platform incorporating video, illustration, and text-based content in addition to interactive games to reinforce key constructs.Although several of the care models discussed within the digital care horizon have been piloted or implemented within pockets of care settings or patient populations, broad implementation has been limited. Digitally enabled care models face numerous challenges. First, internet and digital access has been purported to be a “super” social determinants of health, and caution must be taken to ensure development of equitable care models. Digital inclusivity and enablement require health care organizations to work with partners to facilitate internet access, enable use despite digital literacy and readiness and create accessible content across languages and cultures. Second, digital care models must also work for health care providers and not increase “desktop medicine,” worsen burnout, or contribute to attrition. There are likely new roles to serve patients through expertise in patient identification and enrollment within digital solutions, and in digital program monitoring, among others. Payment models, informed by total cost of care from a population health lens and relevant outcomes that are patient-centric will be required to advance current care models into the care models most needed by patients and care teams alike. Finally, it will be imperative to ensure smooth transitions between the levels of the digital care horizon. We will need to leverage experiences and create new insights to determine when a patient can safely be monitored at home or can transition into and out of facilitated self-care models.Strategic partnerships will be a key component of future success in bridging the health care digital divide. Partnership with patients from all social, racial, and ethnic backgrounds will be essential to inform and cocreate solutions meeting the needs of all. Collaboration with value-aligned technology companies to create solutions while protecting patient privacy will be critical to retain patient trust. Strong relationships between institutional information technology groups and clinical teams will ensure that digital tools fit seamlessly into existing workflows and avoid additional clinical burden. Alliances with public and private payers will be necessary to advance payment models supporting hybrid “bedside-webside” care models that are in alignment with the care goals of patients and people who provide care for them.Models advancing our ability to extend care to those with serious and complex medical needs through digital platforms are needed. Moreover, omnichannel digital experiences for patients allowing for personalized care based on medical and social need and ability are also needed. We have drafted the digital care horizon as a means to think about opportunities for extension from the perspective of a health care system to help address these needs. There are frameworks from the technology, device, and individual program spaces and those endorsed by the World Health Organization and the Department of Health and Human Services, which provide those who are designing digital health support tools and programs that extend care to bridge the digital divide.Dr Ebbert receives consulting fees from K Health, SOAP Health, and EXACT Sciences paid to Mayo Clinic. Dr Ebbert receives consulting fees from Applied Aerosol Technologies and MedInCell. The funders had no role in study design, data analysis and interpretation; in writing of the manuscript; and in the decision to submit the manuscript for publication. The findings and conclusions do not necessarily represent the views of the funders.


Objectives: Access to vaccination for newly arrived migrants (NAMs) is a relevant concern that requires urgent attention in EU/EEA countries. This study aimed to develop a General Conceptual Framework (GCF) for understanding how to improve vaccination coverage for NAMs, by characterizing and critically analyzing system barriers and possible strategies to increase vaccination.Methods: A theoretical conceptualization of the GCF was hypothesized based on conceptual hubs in the immunization process. Barriers and solutions were identified through a non-systematic desktop literature review and qualitative research. The GCF guided the activities and facilitated the integration of results, thereby enriching the GCF with content.Results: The study explores the vaccination of NAMs and proposes strategies to overcome barriers in their vaccination process. It introduces a framework called GCF, which consists of five interconnected steps: entitlement, reachability, adherence, achievement, and evaluation of vaccination. The study also presents barriers and solutions identified through literature review and qualitative research, along with strategies to enhance professionals’ knowledge, improve reachability, promote adherence, achieve vaccination coverage, and evaluate interventions. The study concludes by recommending strategies such as proximity, provider training, a migrant-sensitive approach, and data collection to improve vaccination outcomes for NAMs.Conclusion: Ensuring equitable access to healthcare services, including vaccination, is crucial not only from a humanitarian perspective but also for the overall public health of these countries. Access to immunization for migrants, especially for newly arrived migrants (NAMs) is a critical aspect of public health interventions in the European Union and Economic European Area (EU/EEA) . ImmunizMigrants may not be immunized or may be under immunized in their countries of origin and so may be vulnerable to acquire Vaccine Preventable Diseases (VPD). Scientific evidence strongly supports the importance of vaccinations for protecting migrant populations from infectious diseases. Migrants are at higher risk due to unsanitary conditions and limited access to healthcare. Vaccinations are an effective way to prevent the spread of diseases among migrant populations, ensuring their health and the health of the communities they join. Access to immunization services for migrants is crucial for preventing disease outbreaks and promoting their wellbeing and integration into society –5. In thIn 2019, the WHO published a technical guide outlining three essential elements to ensure high vaccination coverage among refugees and migrants: appropriate vaccination services for newly arrived individuals, delivery of immunization services as part of mainstream health services, and targeted and culturally appropriate immunization services . MoreoveThis study aims to develop a General Conceptual Framework (GCF) to understand how to improve vaccination coverage among migrants in EU/EEA countries. Considering all steps taken in the healthcare pathway from the vaccination entitlement to completion of needed vaccination, addressing also dropout, and adopting a life‐course approach to immunization for children, adolescents, adults and elderly. By reviewing existing policies, strategies, and initiatives, including those from the WHO and EU-funded projects, the GCF identifies system barriers and best strategies as well as potential areas for improvement to ensure equitable access to vaccination for all, including NAMs. In doing so, we hope to contribute to the ongoing efforts to achieve universal health coverage and protect public health across EU countries.The GCF was developed through three steps, using mixed-methods: theoretical conceptualization of a Preliminary Conceptual Framework (PCF), non-systematic desktop review and qualitative research  and consolidation of the GCF.A person , who entered the country in the last 12 months EITHER within the procedures prescribed by the governmental migration policies, excluding tourists and short visa/permit <3 months, OR outside the procedures recognized by the legislation (or overstay after visa expired)” and for all questions, distinctions between different legal status of NAMs should be considered. These questions were a useful tool to accurately guide personal interviews/focus groups and characterize and assign all records extracted from the literature review and the qualitative research in the corresponding hub  workshop. Furthermore, to be able to frame the different issues and understand the reasoning behind each hub, the team has formulated specific “Question Groups” (QG) concerning every hub. All questions refer to NAMs according to the AcToVax4NAM operational definition “ hub see .A desktop literature review has been implemented, also at country level, to identify existing research concerning system barriers  and solutions, recommended or suggested, to overcome them. A search strategy was launched on PubMed in order to find scientific articles or documents concerning the topic of interest. The consortium countries integrated the search with materials in local language or contained in national websites . The Focus groups (FGs) and Personal Interviews (PIs) were conducted in Germany, Poland, Spain, Italy, Greece, Malta, and Cyprus, partners of AcToVax4NAM consortium, in order to understand the actual experiences of the “professionals FOR health”  involved in NAMs immunization and to achieve the characterization of system barriers  and identification of possible and sustainable solutions at country level. Eligible participants included: 1) health and social care professionals who work in the field of delivery of immunizations, 2) professionals, who work in managing/organizing immunization services, and 3) experts related to immunization planning. Guidelines for performing FGs discussion and PIs were developed for all partners by Prolepsis Institute to provide a common methodology and ensure a uniform group composition see . FGs disThe GCF and the QGs were utilized to determine and merge the barriers and solutions found during the reading of the desktop literature review and the thematic analysis of the qualitative research. This selection and combination process was guided by their similarities. Subsequently the partners, especially the members of the AcToVax4NAM Steering Committee whichcomprises the project manager and the 6 WP leaders and is the key decision-making and issue-resolution body for the project, sent a two-round of suggestions and comments according to the AcToVax4NAM evaluation plan. These were used for a further revision of the findings, which was then presented to the project Steering Committee meeting and finalized by the end of June 2022.Entitlement to vaccination, 2) Reachability of people to be vaccinated, 3) Adherence (vs. Hesitancy) to vaccination, 4) Achievement of vaccination (execution and completion), 5) Evaluation of vaccination intervention  rvention . As can Entitlement intended to encapsulate “what for whom” and concerns the regulatory planning of the vaccination offer; Reachability is related to “how to whom” and regards all strategies, including the “proximity approach,” and abilities of the health service to get in contact with NAMs; Adherence that framed “how for what” includes the strategies to ensure that NAMs respond positively to the vaccination offer and to devise abilities in the “professional FOR health” to counteract vaccination hesitancy and fear among NAMs; Achievement concerns the execution and completion of vaccination, that is “what (vaccines) and when for whom and how for what” and should depends on organization and flexibility of health services; Evaluation, which should report “how many (vaccinated) among all migrants,” regards the necessity of data collection and information flow about NAMs vaccination to be used for the evaluation of activities  to understand the reasons. The dashed arrows from the Evaluation hub indicate that the evaluation process must be cross-cutting at all hubs and has to take into account their strategies and actions.The dashed arrows in One-hundred and fifty-one documents were collected from the review, 85 documents , containing at least one barrier and/or solution, were selected and analyzed. After the exclusion of 7 documents (not pertinent to immunization), 78 documents were included –20, 21––21–26, –33, 2,3–40, 41––41–79, –83. FromEntitlement, including legal barriers (4.5%) and solutions (2.7%), economic barriers (2.7%) while no economic solutions were found; 44 records were assigned to Reachability, including organizational barriers (5.5%) and solutions (5.5%); 184 records were assigned to Adherence, including legal barriers (0.5%) and solutions (0.2%), economic barriers (2.5%) and solutions (2.2%), organizational barriers (2.5%) and solutions (5.2%), psycho-social barriers (4.7%) and solutions (1.5%) and cultural/linguistic barriers (13.6%) and solutions (12.7%); 129 records were assigned to Achievement, including organizational barriers (14.1%) and solutions (13.4%), cultural/linguistic barriers (2.2%) and solutions (2.2%) and 14 records to Evaluation, including organisational barriers (1.2%) and solutions (2.2%)  and solutions (47.1%) and then assigned to related sub-categories. A total number of 32 records were assigned to s (2.2%) .In total, 117 people participated in 13 FGs and 53 PIs in Germany, Poland, Spain, Italy, Greece, Malta, and Cyprus. Demographic characteristics of health and social care professionals are showed in The methodology that involved the integration of different research tools  into the Preliminary Conceptual Framework permitted a deepening of the processes related to the theoretical conceptual schema produced. The integrated analysis of the findings produced a “fill-in” of the conceptual hubs, previously identified in a theoretical way, producing a greater amplitude, depth and complexity of the dynamics that link the logical hubs of the NAMs vaccination process. In particular, there was a focus on the barriers and solutions that both the literature and the qualitative research identified as relevant in the vaccination process with the aim of making the research more linked to day-to-day operations and stressing their problems and deficiencies. Key findings from Desktop Literature Review and Qualitative research (FGs discussions and Pis) are summarized in After the PCF has been filled in and critically reviewed with the results of the non-systematic literature review and FGs and Pis, the GCF is no longer just a logical framework, but becomes a pathway that can actually strengthen health systems and make vaccination more guaranteed and equitable. Importantly, we need to move from a neutral reading to a critical re-reading, so that the GCF is no longer just a diagram. Despite the heterogeneity and breadth of the results of the analytical work, an attempt has been made in Based on literature review and experiences of health professionals, addressing vaccination barriers for migrants requires a comprehensive and multi-faceted approach. This approach should consider various factors and challenges. The following strategies are essential for overcoming system barriers and promoting successful vaccination interventions for migrants.• Enhancing professional’s knowledge about health rights: Healthcare professionals must be well-informed about migrants’ rights and entitlements to healthcare services. This includes providing continuous training for healthcare personnel and practitioners on the entitlement to health and vaccinations for different profiles of migrants. Furthermore, national, regional, and local authorities should revise their immunisation policies and documents to explicitly mention migrants and NAMs as beneficiaries. This can be done by updating existing documents or creating new ones that clearly state the rights and access to immunisation services for all individuals residing within the country, regardless of their legal status or country of origin.Entitlement to vaccination—this hub focuses on the rights of NAMs to receive vaccinations and the barriers that may arise in relation to their entitlement.• Improving reachability through updated data sources and multi-sector collaboaration: Accurate and up-to-date information about migrant populations is essential for effective outreach. This includes improving data sources by aligning with municipal registers and establishing links between different government departments and the National Health System (NHS). Strengthen cooperation between different levels and sectors, including general practitioners, family paediatricians, clinics for temporarily or undocumented foreigners, family planning units, hospitals, municipalities, non-governmental organizations (NGOs), and other entities that interact with migrants. Involve foreign communities in reaching out to migrants not listed for vaccination.Reachability of people to be vaccinated—this hub addresses the challenges associated with reaching NAMs and ensuring that they have access to vaccination services. It involves proximity strategies to overcome geographical, logistical, and communication barriers.• Promoting adherence through culturally sensitive health campaigns and strategies: Plan health promotion campaigns specifically targeting migrant populations. Provide training to healthcare professionals, including language mediators, on migrant health needs, cultural awareness, vaccination hesitancy, risk communication, and community engagement. Involve migrant communities in promoting vaccinations. Strengthen links with general practitioners and family paediatricians to promote vaccinations for the entire household. Ensure all services that interact with migrants can provide accurate information on vaccination pathways.Adherence to vaccination—this hub deals with factors that influence the adherence of NAMs to the recommended vaccination schedule. It includes considerations like cultural beliefs, language barriers, vaccine acceptance as well as organizational vaccination literacy.• Achieving vaccination coverage through flexible services and better documentation: Develop detailed procedures for the entire vaccination cycle and make them available to vaccine service operators. Improve access to vaccinations by extending days and time slots, facilitating reservation systems, establishing multidisciplinary teams at vaccination centers, setting up local clinics and temporary hubs, and organizing vaccination programs with support from migrant communities and third-sector organizations. Provide necessary support for migrants during the vaccination process, such as linguistic-cultural mediators and information sheets in multiple languages. Enhance communication and relational skills of healthcare professionals in the vaccination field. Facilitate the exchange of vaccine information and certificates between countries, including the availability of vaccination certificates in multiple languages.Achievement of vaccination—this hub encompasses the actions needed to successfully administer vaccinations to NAMs, including effective delivery, monitoring, and follow-up. It involves strategies to ensure that the vaccination process is completed for each individual.• Evaluating interventions through research and monitoring: Conduct surveys or focus groups to understand why certain groups do not benefit from vaccination. Monitor and evaluate the system’s ability to reach migrants, including obstacles and determinants. Study vaccine hesitancy and refusal among migrants, including obstacles and determinants. Analyze vaccination coverage for migrants and strengthen cooperation with local registries and government entities to improve data quality. Develop ways to record additional or booster doses for migrants not enrolled in the NHS.Evaluation of the intervention—this is a cross-cutting hub which focuses on assessing the effectiveness of vaccination interventions for NAMs. It involves monitoring and evaluation activities to measure the impact of the implemented strategies and identify areas for improvement.Proximity strategies: public health strategies focus on fostering relationships between public institutions, private social organizations and communities with the goal of promoting access to services. Key features include networking, a multidisciplinary approach, the use of mobile teams, cultural mediators, and raising provider awareness through the active offer of health services, the orientation to services, the creation of pathways for taking in charge and the involvement of the population in empowerment processes. These strategies help to overcome geographical barriers and encourage better access to healthcare for migrants. Proximity strategies inform the vaccination process and are tailored to each hub, characterizing specific actions related to reachability, adherence and achievement.a) Training courses for providers: the skills and competencies of providers involved in the vaccination process are crucial. Continuous training and updating, are essential for strengthening the health system and other sectors involved in vaccination. In Germany, the Robert Koch Institute (RKI) offers a range of training courses and resources for healthcare providers involved in vaccination services. These courses include topics such as vaccination schedules, vaccine storage and handling, and communication skills to effectively engage with diverse populations, including migrants. Training improve the system’s ability to reach NAMs, especially those in the hard-to-reach groups (reachability), offer and promote vaccinations, particularly also in countering vaccination hesitancy (adherence), and carry out vaccinations (achievement). Training is also a key element in developing proximity strategies should involve all stakeholders involved in the vaccination process.b) Migrant sensitive approach: effective vaccination promotion, organization, and delivery require sensitivity to the unique differences of migrants, including age, gender, legal status, economic status, and more. Investing in multidisciplinary and multi-sectoral training and retraining helps strengthen the migrant-sensitive approach. In the United Kingdom, the NHS has initiated several programs to improve vaccination rates among migrants, such as offering translated materials in various languages, providing cultural competency training for healthcare providers, and using community leaders to promote vaccine uptake.c) Data source: improving vaccination data collection among migrant populations is critical for developing appropriate health policies and services. Hub-specific Standardized Operating Procedures (SOPs) can enhance the quality of the vaccination process by facilitating information sharing within systems at various level. Access to disaggregated data enables better estimation of vaccination coverage, strengthens evaluation for each identified hub and improve the vaccination process in that hub. Particularly important is the registration of vaccinations and linking national and supranational databases to address the mobility of migrant populations. In the European Union, the ECDC has developed a project called “Vaccine Schedule” that gathers information on vaccination schedules and policies across EU/EEA countries. This project aims to improve data collection and sharing between countries to better understand vaccination coverage and gaps in migrant populations.d) Certain strategies can simultaneously address the purposes of different hubs and fulfill unique purposes concurrently. The following strategic lines encompass multiple hubs: The purpose of this study was to develop a General Conceptual Framework (GCF) to understand how to improve the vaccination coverage for NAMs in EU/EEA. The GCF can help improve vaccination coverage for NAMs by providing a systematic approach to identifying and addressing barriers throughout the vaccination process. The methods used to identify barriers and solutions in the study were a combination of literature review and qualitative research. The literature review involved analysing relevant publications and categorizing the barriers and solutions into different subcategories. The study examined legal, economic, organizational, psycho-social, and cultural/linguistic barriers and strategies associated with entitlement, reachability, adherence, achievement, and evaluation. Additionally, qualitative research was conducted through focus groups and interviews with health and social care professionals in Germany, Poland, Spain, Italy, Greece, Malta, and Cyprus. These participants provided valuable insights into the implementation of vaccinations for NAMs and contributed to the identification of barriers and potential strategies to overcome them. The findings from both the literature review and qualitative research were used to develop the GCF and inform the recommendations for improving vaccination coverage for NAMs. The five conceptual hubs provide a framework for understanding the different stages and challenges in improving vaccination coverage adopting also a life‐course approach to immunization for children, adolescents, adults and elderly.The framework especially helps in identifying specific barriers and possible strategies at each stage of the vaccination process. For example, it can highlight issues related to entitlement, such as ensuring that healthcare worker understand migrants’ rights to receive vaccinations and have their access to vaccination services , 19. It However, the study acknowledges the lack of international agreement on the definition of NAMs, which poses limitations in data collection and in understanding and addressing their specific needs. The AcToVax4NAM project has developed an operational definition of NAM based on public health considerations and guidelines, with the aim to include a wide range of people on the move, regardless of the person’s legal status or country of origin. It takes into account all ages and emphasizes the ability of the healthcare system to assess vaccination status and, if necessary, provide appropriate vaccinations. Although it was developed in a project for NAMs, we have also realized through the literature review and focus groups that the GCF can also be used for migrants who have been in the country for a longer period of time.The study also calls for collaboration with other European projects to extend consensus on the definition of NAMs and create a greater network among countries. In fact, although the applicability of the GCF may vary across countries due to differences in healthcare systems, definitions of NAMs, and other contextual factors, the framework provides a starting point for addressing vaccination coverage challenges. By comparing the findings of the GCF with relevant literature and adapting it to specific country contexts, policymakers and healthcare providers can tailor their strategies to improve vaccination coverage for NAMs effectively. Based on our extensive literature review, we have found no existing conceptual framework that precisely outlines the vaccination process for NAMs, as illustrated in this study.This study also suggest to create and adapt SOPs and country specific action-oriented flow-chart by drawing from the 5-hub of the GCF. SOPs should cover all aspects of vaccination and be implemented at the national level by all relevant health services. This will allow all stakeholders involved to know what to do, how to do it and with whom it is important to collaborate, as there is not one-size-fits-all model for national health systems or migrants’ rights. Finally, advocating for migrants’ rights to healthcare and promoting inclusive policies can help create a supportive environment for vaccination efforts. Engaging policymakers, civil society organizations, and other stakeholders can lead to the development of policies that prioritize migrants’ health and wellbeing.In conclusion, vaccinations play a crucial role for NAMs, as they may be a vulnerable group in need of protection from infectious diseases. During their journey and settlement in a new community, migrants can be exposed to poor hygiene conditions and limited access to medical care, increasing their vulnerability to infectious diseases. Vaccinations represent an effective means to prevent the spread of infectious diseases within migrant populations, protecting not only the migrants themselves but also the host communities. Ensuring that migrants have equal access to immunization services reduces the risk of outbreaks and the spread of diseases within communities. Furthermore, it promotes the wellbeing and integration of migrants, leading to healthier and more inclusive societies. Overall, the GCF developed in this study will serve as a blueprint for each country to develop their own action-oriented flow charts/SOPs based on the specific barriers and proposed strategies identified. The framework will help improve vaccination coverage for NAMs, taking into consideration different NAMs categories, the heterogeneity of settings, age groups, and special groups such as pregnant women. Countries should define specific actions, responsible parties, and timelines in their unique contexts, while reflecting on the necessary resources.


Patients with head and neck cancer (HNC) often experience various types and degrees of complications and functional impairment following surgery or radiotherapy. Consequently, these patients require extensive postdischarge rehabilitation, either at home or in the community. Numerous studies have shown the advantages of mobile Health  technology in assisting patients with cancer with self-management and rehabilitation during the postdischarge period. However, few reviews have focused on the intervention, management, and evaluation of mHealth technology in postdischarge patients with HNC.This study aimed to conduct a scoping review of mHealth technology apps and interventions currently available to patients discharged from hospitals after receiving treatment for HNC. This study sought to identify and summarize the types and effectiveness of existing mHealth interventions as well as the differences in their outcome assessments.The PubMed, Embase, Web of Science, and CINAHL databases were used to identify studies with no publication time limits. The keywords “mobile health technology” and “head and neck cancer” were combined to address the main concepts of the research questions.Of the 1625 papers identified, 13 (0.8%) met the inclusion and exclusion criteria. Most studies  were randomized controlled trials (RCTs) and cohort studies. These studies were conducted in 6 countries. The main aims of the mHealth interventions in these studies are as follows: (1) symptom monitoring and assessment, (2) rehabilitation training, (3) access to medical health information, (4) telehealth advisers, (5) peer communication and support, and (6) follow-up/review reminders. The outcome evaluations of the 13 included studies were grouped into 4 categories: (1) technology usability and patient satisfaction, (2) self-management of symptoms and patient-reported outcome–related indicators, (3) adherence, and (4) health-related quality of life.A limited number of studies have investigated the use of mHealth technology in the postdischarge self-management of patients with HNC. The existing literature suggests that mHealth technology can effectively assist patients with HNC in self-management and postdischarge interventions. It plays an important role in addressing patients’ health information needs, reducing both their somatic and psychological burdens, and improving their overall quality of life. Future research should prioritize conducting additional high-quality RCTs to evaluate the usability and analyze the cost-effectiveness of mHealth technology. Malignant head and neck tumors, one of the most common malignancies, are classified according to the site of tumor origin into oral cavity, nasopharyngeal, oropharyngeal, and laryngeal cancers. Among these, head and neck squamous cell carcinoma (HNSCC) accounts for >90% of all head and neck tumors. The latest statistics of the International Agency for Research on Cancer (IARC) GLOBOCAN on global cancer incidence and mortality in 2020 revealed 890,000 new cases of HNSCC, with 450,000 resulting deaths annually . The incSurgical resection, radiation, chemotherapy, targeted therapy, and a combination of these therapies are the available treatment options for head and neck cancer (HNC). Patients with various tumor stages and locations receive individualized treatment approaches . HoweverStudies have shown that patients with HNC frequently experience increased functional impairment and negative side effects after surgery or radiotherapy. Short-term home rehabilitation after discharge is crucial for enhancing patients’ function and long- and short-term quality of life (QoL) because brief rehabilitation care treatment during hospitalization is insufficient to assist patients in achieving full recovery. Although patients have continuous access to medical care and guidance from doctors and nurses while they are in the hospital, they must assume responsibility for their own functional rehabilitation and self-care after discharge, whether they return home or move to other facilities, such as community nursing homes. Most patients and their family caregivers lack a medical background, and despite receiving necessary verbal health education or health information booklets by doctors and nurses before discharge, forgetfulness inevitably occurs over time. As a result, survivors of HNC may continue to experience significant debilitating issues with swallowing, speech, hearing, and psychological effects due to loss of function and changes in their body image as a result of treatment. Survivors of HNC often experience a lower QoL -6. StudiWith the increasing application and popularity of mobile health  technology, numerous studies have shown that mHealth technology has the potential to assist patients with cancer and other chronic diseases in self-management ,9. mHealThis study systematically reviewed the use of mHealth technology in the postdischarge self-management of patients with HNC. The review centered on 2 sections: intervention and outcome evaluation. The aims of this study were (1) to summarize the categories of mHealth interventions and their main types of functions/services for the postdischarge self-management of patients with HNC through a systematic review of the existing literature and (2) to examine how these mHealth interventions are evaluated and the differences that exist between outcome indicators across studies.This study used the 5-stage methodological framework outlined by Arksey and O’Malley  to definThe study population included adult patients with HNC who had been discharged from the hospital after surgical treatment or radiotherapy and were recovering at home or in the community. The type of intervention involved the use of mHealth technology. The research questions were developed based on an initial literature search and further refined through iterative discussions within the research team. The research questions were as follows: (1) What mHealth technologies exist to support patients with HNC after hospital discharge? (2) How are these mHealth technologies used to implement interventions? (3) How are mHealth interventions evaluated?A systematic search strategy was used to identify the literature related to the research questions. We combined the keywords “mobile health technology” and “head and neck cancer” according to the patient/problem, intervention, comparison, and outcome (PICO) principles of literature search, which identified the 2 main concepts of the research questions and summarized the subject terms and free words related to these 2 main concepts. Systematic searches were conducted in the PubMed, Web of Science, Embase, and Cumulative Index to Nursing & Allied Health (CINAHL) databases. Two independent researchers (authors LYF and CWH) searched the databases for references to identify papers published between the time of database creation and March 1, 2023. The search terms and strategy used are presented in The inclusion and exclusion criteria for this review are presented in Inclusion criteria:Adult patients including both males and females (≥18 years old)Patients with head and neck cancer (HNC) who have been discharged from the hospital to recover in a nonmedical setting, such as their homes or communities, after undergoing at least 1 surgical or radiotherapy treatmentUse of mobile health  technology to implement interventionsEnglish papers onlyContains at least 1 quantitative resultSelection of a paper by the same research team (same app) on a specific system for inclusion in the analysisExclusion criteria:Participants aged <18 years Integrated interventions that do not use mHealth technology alone but in other collaborative ways, such as multidisciplinary cooperationFull-text documents not available, such as conference abstracts or protocols, as well as review papersNo specific outcome evaluation indicators related to HNCWe collaborated to develop a graphical form of the data and to identify variables to be extracted. Descriptive graphical information included (1) a general description of the paper  and (2) intervention-specific information ; see General descriptions of review papers were collated according to the descriptive characteristics. Following a concurrent review of the chart data, we conducted a thematic content analysis of the interventions and associated outcomes for each study. First, codes were developed and applied to analyze the data. The coding segments for all chart data were created using color-coded quotes. The code summaries were organized in a Microsoft Excel table for thematic content analysis. The table was sorted by code and density, looking for repeating patterns addressed by the included papers, including a comparison of the studies across the data set and within each study until key themes were identified. The results of this study summarize the objectives.In total, 1625 papers were retrieved, of which 1489 (91.6%) different papers remained after removing duplicate data. Of the 13 studies included in this review, RCTs  were the most common type , followeCurrent mHealth interventions and management services for the population with HNC postdischarge include 6 main categories: (1) symptom monitoring and assessment reports  technology usability and patient satisfaction, (2) indicators related to self-management of symptoms and patient-reported outcomes (PROs), (3) adherence, and (4) health-related quality of life (HRQoL).This study found that mHealth technology plays a more beneficial role in the postdischarge management of patients with HNC. The mHealth program helped improve physical and psychological symptoms after discharge, enabled patients to gain more knowledge about health care, and enhanced their self-management of behaviors and functional rehabilitation exercises after leaving the hospital. Patients in these studies showed high levels of satisfaction with and acceptance of mHealth technologies.Of the 13 included studies, 8 (61.5%) focused on the impact of mHealth technology on symptoms and the validity of outcome reporting.Of these 8 (61.5%) studies, 2 (25%) discussed the impact of mHealth technology on the effectiveness of PROs. Ma et al  found thDue to the significant symptom burden associated with HNC, mHealth technology may be beneficial in assisting patients with symptom management. Van Cleave et al  developeNext, 6 (75%) studies discussed the effect of mHealth technology on patients’ symptom self-management. The mobile app SwallowIT was tailored to provide telepractice-assisted therapy to patients with swallowing disorder during radiotherapy and after HNC treatment to support home practice of the pharyngeal program . The proLin et al  developeThe mobile app Oncokompas, developed by Dutch academics, can support symptom self-management by providing medical information and a personalized overview of supportive care options aimed at reducing the symptom burden among survivors of cancer . The resWang et al  used telRegarding complication management, an RCT  with patOf the 13 included studies, 4 (30.8%) investigated technology usability and patient satisfaction in outcome evaluations. Patients demonstrated higher satisfaction with the mHealth technologies in all study outcomes.In terms of technology usability, software usability refers to the extent to which a particular user can use a product in a specific context and achieve a particular goal effectively, efficiently, and satisfactorily. Patient satisfaction with a fully automated interactive chatbot  reached P<.05) in terms of the intention to use, perceived usefulness, and ease of use after 3 months of the intervention.In the SwallowIT study , 76% of These data show that patients’ use of and familiarity with mHealth apps reduce their uncertainty and improve their acceptance of the new technology. This, in turn, can promote better adoption and use of mHealth technology in the future and enhance its overall usability.Most studies  measured and evaluated the HRQoL. Of these, 6 (66.7%) studies ,19,21-24There were mixed results regarding the improvement in the QoL with mHealth technology in the studies. The mobile app SwallowIT was not associated with statistically significant improvements in the final overall QoL . HoweverOf the 13 included studies, 5 (38.5%) reported on adherence to the use of mHealth technology. In the SwallowIT app [P<.05). However, changes in adherence within groups were not elaborated. The researchers concluded that mHealth technology can provide pictures and videos to be viewed repeatedly, and all these activities can be performed with the help of relevant videos as a means to improve patient adherence.The results of an RCT  showed tThe ePVA study  showed tThe HNC Virtual Coach study  conducteAdditional support for the intervention exercise program for patients with restricted mouth opening was provided by remote telephone support , which sIn this review, 13 papers were analyzed. Some studies have indicated that patients with HNC frequently experience increased functional impairment after surgery. Brief rehabilitation during hospitalization may not be adequate to help patients recover, while long-term home-based rehabilitation after discharge plays a crucial role in improving patients’ function and long- and short-term QoL. Therefore, this study focused on assessing how patients use mHealth technology for self-management, functional rehabilitation, and related outcome evaluation indicators after hospital discharge.This scoping review summarized the existing literature on mHealth technology for the postdischarge self-management of patients with HNC and the intervention tools, intervention methods, and types of outcome evaluations of mHealth technology in the currently available literature, following a generalization and thematic summary.mHealth technology can accelerate patient communication, facilitate home monitoring and self-management, and improve overall patient health. The use of mHealth in the postdischarge self-management of patients with HNC addresses many issues and offers several advantages, including the following:Real-time monitoring and tracking: Although patients are the best recorders of their daily health experiences, clinicians and others are unlikely to have full access to patients in their living environments after hospital discharge. Consequently, capturing timely information about patients’ actual experiences, health status, and outcomes can be challenging. mHealth apps can help patients monitor and track their health in real time. Using sensors and devices, patients can measure physiological metrics  and record them. These data can be shared with doctors to better understand their condition and make necessary adjustments to the treatment plans. Meanwhile, because PROs have become the focus of health care research, scholars have begun to explore whether mHealth technology can be an effective tool for PROs. Findings have shown that the use of mHealth technology can help patients with daily symptom recording and outcome reporting. Furthermore, PROs have demonstrated strong concordance with CROs .Personalized health management: mHealth technology can provide a platform for patients and their families to obtain different health services in the face of different needs, as well as better intervention and management of patients after they leave the hospital. mHealth apps can provide personalized health management solutions tailored to individual patient differences and needs. The apps can provide customized dietary advice, exercise plans, medication reminders, follow-up reminders, and other functions according to the patient’s condition and treatment plan, thereby helping them effectively manage their health.Education and information resources: While patients are receiving treatment within a hospital, doctors and nurses can provide a steady stream of health care support, including daily treatment, health information, and guidance. In contrast, once patients are discharged, although doctors and nurses may initially explain the key points of posthospitalization rehabilitation and care, the passage of time and various factors, both subjective and objective, such as patient compliance, can make it challenging for patients to effectively self-manage their physical and psychological well-being. mHealth apps can provide patients with health education and the necessary information resources they require anytime, anywhere. Patients can access professional medical knowledge about diseases, treatment options, medication, and more through these apps while they are at home, helping them better understand their condition, treatment options, recovery methods, etc.Social and psychological support: Due to factors related to the disease and treatment modalities, patients with HNC usually face issues concerning an altered body image, which may also affect their ability to resume work and engage in social activities. Therefore, social and psychological support for these patients requires careful consideration. However, this is a long-term process that cannot be fully addressed and promptly implemented during hospitalization. mHealth apps connect patients with other patients or health care professionals to provide social and psychological support. Patients can use these apps to share their experiences and offer advice to other patients. Moreover, they can have online consultations and communications with health care professionals, thus reducing anxiety and the feeling of isolation.Improving adherence: Undoubtedly, for doctors and nurses, managing and providing follow-up care for discharged patients pose a significant challenge. The brief, 1-time health education at the time of discharge makes it difficult to address the various medical, health, and psychosocial difficulties encountered by patients during home rehabilitation and to help patients establish good self-management ability and compliance with home treatment. Patients who leave the hospital often experience problems during the follow-up phase, including difficulty in communication, difficulty in management, poor adherence, suboptimal recovery, and a poor QoL. mHealth apps, however, can provide medication reminders, treatment plan tracking, and other functions to help patients better follow doctors’ advice and treatment plans.These findings suggest that novel mHealth technology is more likely to be welcomed by the patient population than traditional forms of follow-up and that patients who use mHealth technology show better adherence ,14,17-19Overall, the advent of mobile technology has transformed the health ecosystem by changing the way individuals communicate and providing patients and health care providers with a wide range of supportive tools to monitor and manage health information, thereby facilitating better health care delivery. The advantages of mHealth in the home self-management of patients with HNC after discharge from the hospital include real-time monitoring, personalized health management, access to educational and information resources, social and psychological support, and improved treatment adherence. These benefits can help patients more effectively manage their health, improve their QoL, and work closely with their health care teams.Although most studies have demonstrated the positive impact of mHealth technology on the postdischarge self-management of patients with HNC, some have shown no significant improvement in patient self-management with respect to other outcome indicators . This maIn addition to physical and psychological outcome indicators, few studies have examined standard technical usability evaluations and economic efficiency indicators. Wall et al  reportedAs the number and scale of mobile apps increase with the increasing use of mHealth technology, more attention should be paid to usability evaluation throughout the software development process. Timely usability evaluation before, during, and after development is an important measure for understanding user needs, improving the design of software features, and improving user experience and satisfaction. However, this is not well described in existing research.At the same time, we must also consider the impact of mHealth technology on doctors and nurses, even as it brings convenience to patients. Questions regarding whether the use of mHealth technology consumes additional time for health care professionals, whether it increases their workload beyond their regular work, whether health care professionals are satisfied with their mHealth technology experience, and how hospital managers reconcile conflicts and contradictions arising from this technology are all aspects that have received less attention in existing research. Therefore, future research should explore these areas to achieve a comprehensive understanding.Finally, the issues of data privacy and security should be given sufficient attention. mHealth apps handle large amounts of personal health data; therefore, data privacy and security are important concerns. Ensuring the security and privacy of patient data is challenging, and appropriate security measures must be adopted to protect such data.By addressing the limitations and research weaknesses of this study, future research can advance to explore the effectiveness of mHealth technology in the postdischarge self-management of patients with HNC. This can be achieved through rigorous methods, such as conducting an RCT with a robust study design, expanding the scope of the study and the number of users, and adopting scientific theoretical guidance for the selection and evaluation of outcome indicators.Hotspots for future research will also focus on the application of artificial intelligence in mHealth, the integration of virtual reality and augmented reality technologies in oncology treatment, and the development of remote monitoring and diagnosis based on mobile devices. Future research will also need to overcome various challenges, including issues related to data privacy and security, technology usability and ease of use, data analysis and use, and evaluation of the effectiveness and efficacy of mHealth apps. Addressing these challenges requires interdisciplinary collaboration and sustained research efforts.This study was a scoping review conducted to broadly include and summarize the existing literature. In addition, this study only included studies published in English, and studies published in other languages were excluded from the discussion.mHealth technology has been applied to the postdischarge self-management of patients with HNC. The main interventions in mHealth technology for improving postdischarge self-management include symptom monitoring and reporting, functional rehabilitation training, access to health care information, telehealth service support, peer-to-peer communication, and follow-up/review reminders. Outcome evaluations of the use of mHealth technology were discussed in terms of technology usability and patient satisfaction, indicators related to self-management of symptoms, PROs, adherence, the HRQoL, and the impact on somatic/psychological aspects, with most studies showing a positive impact.Therefore, based on the limited research data available to date, mHealth technology can effectively help patients with HNC in self-management and postdischarge interventions. This plays an important role in meeting patients’ health information needs, reducing their somatic and psychological burdens, and enhancing their QoL. Future research should aim to conduct higher-quality RCTs for usability evaluation and cost–economic benefit analysis.