Introduction

Care transitions occur when a patient moves from one health care setting to another, such as from hospital to home. Effective care transitions are critical for ensuring that patients receive safe, high-quality care and for reducing the risk of adverse events, such as medication errors or unnecessary hospital readmissions []. However, care transitions are often complex and often involve multiple health care providers. In addition, recently hospitalized patients typically experience a temporary period of generalized risk of a wide range of adverse health events, also called “posthospital syndrome” []. Consequently, care transitions can be a significant source of errors, delays, and gaps in care [,]. One critical gap that has been identified is poor communication among clinicians, patients, and their caregivers [,], which is the one aspect that we hypothesize can be addressed through better technology solutions.

Technological solutions that can help improve the transition of patients between different care settings or health care providers are often referred to as “platform-based patient-clinician digital health interventions (DHIs).” These interventions can be used to address challenges during care transitions by leveraging technology to improve communication, coordination, and information sharing between clinicians and patients. These interventions can include but are not limited to providing patients with (1) personalized care plans, reminders, and educational resources to support self-management during transitions []; (2) remote monitoring to help health care providers track patient vital signs and symptoms to detect early warning signs of complications []; and (3) exchange and communication of information between clinicians and patients [].

Previous research has identified 10 key elements in an ideal care transition []. The key domains of the Ideal Transition of Care framework [] comprise (1) discharge planning; (2) complete communication of information; (3) availability, timeliness, clarity, and organization of information; (4) medication safety; (5) patient education to promote self-management; (6) social and community supports; (7) advanced care planning; (8) coordination of care among team members; (9) symptom monitoring and management after discharge; and (10) outpatient follow-ups. This framework was created to establish the necessary considerations pertaining to safe transitions in care. Ideally, any DHIs being developed would consider these proposed domains.

Platform-based patient-clinician DHIs can also facilitate continuity of care. Continuity of care is an important aspect that is present when a patient experiences coherent and linked care over time or when discrete elements of care that endure over time are maintained and supported []. Although continuity of care can be interpreted differently between care providers, there are 3 types that are agreed upon. The first type is “informational continuity,” which refers to the use of data from previous events in a patient’s medical history to inform the appropriate care of the patient’s current encounter []. The second type is “management continuity,” which occurs when care from multiple health care providers is linked in a coherent manner []. The third type is “relational continuity,” which acknowledges the importance of the relationship between patients and providers [].

In addition, platform-based patient-clinician DHIs for care transitions have the potential to encourage individual behavior change and reduce health care costs []. It is important to ensure that these interventions are evidence based, user-friendly, and aligned with patient preferences and needs. There are limited reviews on DHIs for discharge and transitional care use, and these reviews focus mainly on a specific health aspect or condition, such as self-care associated with surgery [] or postsurgery care for patients with hip fracture []. One other review identified specific health care provider roles and functions related to the use of DHIs []. Given that patients often have multiple health conditions, there are, to our knowledge, no reviews to date examining the use of DHIs during care transitions across various conditions to reduce siloed care. The aims of this scoping review were to explore the literature on platform-based patient-clinician DHIs specific to hospital-to-home care transitions and identify the barriers to and enablers of the uptake and implementation of these platform-based patient-clinician DHIs.

MethodsDesign

We conducted a scoping review based on the work by Arksey and O’Malley [], Levac et al [], and the Joanna Briggs Institute scoping review methodologies []. The study is reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist [] (). The methods involved five steps: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; and (5) collating, synthesizing, and reporting the results. The detailed protocol has been published previously [].

Search

A peer-reviewed search [] was conducted on July 13, 2022, in MEDLINE, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials (). The main search concepts comprised terms related to “hospital to home transition,” “patient discharge,” “transitional care,” “internet-based interventions,” “mobile applications,” “mhealth,” and “digital health” platforms and were informed by previously conducted systematic searches [,,]. No limit to language was applied; however, the results were limited by a publication date from 2012 onward. We chose to review results from the previous 10 years, recognizing the rapid pace of technological advancements. Search results were exported to Covidence (Veritas Health Innovation), a systematic review software [], and duplicates were removed using the platform’s duplicate identification features.

Screening

Studies were screened in 2 steps (title and abstract, and full text) based on the eligibility criteria ().

Textbox 1. Inclusion and exclusion criteria.

Inclusion criteria

Population: adult patients (aged >18 y) discharged from hospital to homeConcept: digital-based platforms that support a hospital-to-home transition, including web-based digital health interventions (DHIs), defined as programs that were delivered via the internet and accessed through a website link (URL) [], and mobile apps, defined as software programs developed for smartphones []Context: hospital-to-home transitionsType of evidence: studies published after 2012 and identified as randomized controlled trials, quasi-experimental studies, pilot studies, feasibility studies, observational studies (case-control, cohort, cross-sectional, and descriptive studies), or qualitative studies

Exclusion criteria

Concept: non–platform-based DHIs, including but not limited to wearable devices if the intervention was stand-alone (eg, to track activity), prosthetics, robotics, medical imaging technology (eg, x-rays and ultrasounds), interventions using only a standard telephone, machine learning, and telehealthType of evidence: studies in the design stage at the time of screening or if the platform-based patient-clinician DHIs were tailored specifically to and solely focused on mental health or cancer as these are unique clinical areasData Charting

Studies that met all the inclusion criteria were extracted using the Google Forms platform. The pilot-tested Google Form used a survey format for the extraction of the relevant information, including the following: lead author, year of publication, country, objectives, study design, participants, patient health condition, name of DHI, rationale of intervention, theory guiding the intervention, content of the intervention, elements of postcare, digital health tools, function of digital health tool, management or informational or relational continuity of care [], who provided the intervention, number of days after discharge, number and duration of sessions, tailoring or modification, adherence or attrition, results, and barriers or enablers. To ensure a high-quality description of the interventions, the information extracted from each study was guided by the recommendations made by the 12-item Template for Intervention Description and Replication []. After data charting was completed, the Google Form was used to generate a Microsoft Excel spreadsheet to analyze the findings using descriptive and narrative methods.

ResultsOverview

A total of 12,752 records were retrieved from the search, of which 4430 (34.74%) were duplicates and 7837 (61.46%) were rejected at the abstract review stage, leaving 485 (3.8%) records selected for full-text review. A total of 34.2% (166/485) of the reports could not be retrieved as the full text was unavailable. In addition, 222 full-text articles were excluded for the following reasons: incorrect intervention (not DHIs related to care transitions; n=196, 88.3%), language other than French or English (n=15, 6.8%), incorrect study design (n=9, 4.1%), and incorrect patient population (n=2, 0.9%). The list of articles with reasons for exclusion can be found in . The final review included a total of 97 studies after the assessment process was completed ( []).

‎Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram—digital heath interventions (DHIs) for care transitions. Characteristics of the Included Studies

Of the 97 included studies [-], 34 (35%) were conducted in the United States [,,,,,,,,,-, ,,-,,,,,,,,,-,,,,], 16 (16%) were conducted in Canada [,,,,,,,,,,,,,,,], 10 (10%) were conducted in China [,,-,,,,], 8 (8%) were conducted in the Netherlands [,,,,,,,], and 5 (5%) were conducted in Australia [,,,,]. The remaining 25% (24/97) of the studies were conducted in 14 other countries [,,,,,,-,,,,,,,,,,,,,,]. The 2 most common health conditions relevant to the platform-based patient-clinician DHIs were cardiac disease (22/97, 23%) [,,,,,,,,-,,,,, ,,,,,,] and stroke (11/97, 11%) [,,,,,,,,,,].

A wide variety of elements of postcare were implemented in the platform-based patient-clinician DHIs, including but not limited to detecting postoperative issues, assessing patients’ needs, improving patient understanding, rehabilitation, improving symptom management, and increasing self-care ().

Table 1. Study characteristics.StudyCountryStudy designSettingParticipantsHealth conditionName of DHIaDigital health toolElements of postcareAgri et al [], 2020SwitzerlandRetrospective monocentric cohort studyCommunity or home or retirement homePatients—intervention: n=43Colorectal surgery (colorectal resections, ostomy procedures, and stoma closures)MaelaMobile appEnhancing patient-provider communication; ability to identify symptoms of poor wound healing; enhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; pain control or management; wound careAntypas and Wangberg [], 2014NorwayRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=7; control: n=12Cardiovascular diseaseInternet- and mobile-based tailored intervention to enhance maintenance of physical activity after cardiac rehabilitationMobile app and web appImproving physical activityArmstrong et al [], 2017CanadaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=32; control: n=33Ambulatory breast reconstruction surgeryQoCb Health Inc mobile appMobile appAbility to identify symptoms of poor wound healing; detecting any postoperative issues; improving symptom management; follow-up appointments with primary care provider; pain control or management; wound careAthilingam et al [], 2017United StatesFeasibility (pilot) study; randomized controlled trialCommunity, home, or retirement homePatients—intervention: n=9; control: n=9Congestive HFcMobile app to improve self-care behaviors and quality of life for patients with HFMobile appIncreasing self-care; medication management; fostering treatment adherence; improving quality of life; enhancing HF-specific knowledgeAvci and Gozum [], 2018TurkeyDescriptive studyCommunity, home, or retirement homeCaregivers—intervention: n=62StrokeSupportive website for the caregivers of patients with stroke after dischargeWeb appEnhancing caregiver preparedness; enhancing caregiver knowledge and skillsBackman et al [], 2020CanadaFeasibility (pilot) studyCommunity, home, or retirement homePatients: n=34; caregivers: n=19; clinicians: n=37Hip fractureMyPath to HomeWeb appPromoting communication among patients, caregivers, and cliniciansBäcker et al [], 2021GermanyRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=20; control: n=15Knee arthroplastyGenuSportMobile appRehabilitation (physical therapy and occupational therapy)Bauwens et al [], 2022FranceCase-controlCommunity, home, or retirement homePatients—intervention: n=32; control: n=101ACLd reconstruction surgeryDoct-UpMobile appEncouraging ambulation; pain control or management; rehabilitation (physical therapy and occupational therapy)Ben-Ali et al [], 2021CanadaFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=1108Cardiac surgerySeamlessMDMobile appEnhancing patients’ knowledge, skills, and confidence; improving patient understanding; increasing self-care; detecting any postoperative issues; encouraging lifestyle changes; improving symptom management; pain control or management; wound care; providing PROse, surveys, and feedbackBirkhäuser et al [], 2020SwitzerlandProspective nonrandomized pilot clinical trialCommunity, home, or retirement homePatients—intervention: n=18Radical cystectomyCellphone-based health care appMobile app and web appMonitor progression of patient recoveryBlewer et al [], 2020United StatesRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=699; control: n=626Coronary artery diseasemApp CPRf training appMobile appProviding effective CPRBouwsma et al [], 2018The NetherlandsRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=227; control: n=206Hysterectomy and laparoscopic adnexal surgeryeHealth interventionWeb appAbility to identify symptoms of poor wound healing; enhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; improving symptom management; guidance in the process of resuming work activitiesBouwsma et al [], 2018The NetherlandsRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=227; control: n=206Hysterectomy or laparoscopic adnexal surgeryeHealth interventionWeb appEnhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; encouraging return to workCheng et al [], 2022ChinaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=19; control: n=20Hip fractureHome-based rehabilitation mobile appMobile appEnhancing caregiver knowledge and skills; enhancing patients’ knowledge, skills, and confidence; improving physical activity; rehabilitation (physical therapy and occupational therapy); fostering treatment adherence; progress summary (can track completion of tasks), reminders, and support informationCox et al [], 2015AustraliaFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=10Cystic fibrosisActivOnlineWeb appImproving physical activity; encouraging lifestyle changes; improving symptom management; improving quality of lifeDavis et al [], 2020United StatesRetrospective reviewCommunity, home, or retirement homePatients—intervention: n=47Total shoulder arthroplastyForce TherapeuticsMobile appEnhancing patient-provider communication; enhancing patients’ knowledge, skills, and confidence; rehabilitation (physical therapy and occupational therapy)Davoody and Hägglund [], 2016SwedenQualitative studyCommunity, home, or retirement homeCare professionals—intervention: n=8StrokeeHealth for postdischarge strokeWeb appImprove patient understanding; rehabilitation (physical therapy and occupational therapy)De Batlle et al [], 2021SpainProspective, pragmatic, 2-arm, parallel-implementation trialCommunity, home, or retirement homePatients—intervention: n=48; control: n=28Chronic obstructive pulmonary disease and HFCONNECAREMobile app and wearable deviceEnhancing patient-provider communication; monitoring pulse, oxygen, HRg, BPh, and weight at home; enhancing patients’ knowledge, skills, and confidence; improving physical activity; assessing patients’ needsDebono et al [], 2016FranceFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=60Ambulatory lumbar discectomyMobile app for postoperative monitoring after outpatient lumbar discectomyMobile appEnhancing patient-provider communication; assessing rates of complications; pain control or managementDebono et al [], 2019FranceRetrospective analysisCommunity, home, or retirement homePatients—intervention: n=1920; control: n=1563Spinal cord injury and lumbar disc herniatione-fitbackMobile appEnhancing patient-provider communication; detecting any postoperative issues; pain control or management; wound careDevito Dabbs et al [], 2016United StatesRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=99; control: n=102Lung transplantPocket PATHiMobile appDetecting any postoperative issues; assessing patients’ needs; assessing rates of complications; pain control or managementDorsch et al [], 2021United StatesRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=42; control: n=41HFManageHF4LifeMobile app and monitoring devicesEnhancing patients’ knowledge, skills, and confidence; increasing self-care; encouraging lifestyle changes; improving symptom management; assessing patients’ needs; medication management; nutrition support; improving quality of lifeDuan et al [], 2018ChinaPilot randomized controlled trialCommunity, home, or retirement homePatients—intervention: n=44; control: n=39Coronary artery diseaseHealth behavior intervention for patients with coronary heart disease through the webWeb appImproving physical activity; improving food consumptionDukeshire et al [], 2012CanadaFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=31HysterectomySAFERj projectWeb appImproving symptom management; ability to identify symptoms; postsurgical careEustache et al [], 2023CanadaCohort studyCommunity, home, or retirement homePatients—intervention: n=94; matched cohort: n=256Colorectal surgerySame-day discharge mHealthk app (CareSense)Mobile appEnhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; enhancing patient-provider communicationFelbaum et al [], 2018United StatesProspective cohort studyCommunity, home, or retirement homePatients—intervention: n=56Spinal cord injury, lumbar disc herniation, and neurosurgery (spinal and cranial surgery)TrackMyRecoveryMobile appEnhancing patient-provider communication; ability to identify symptoms of poor wound healing; detecting any postoperative issues; pain control or management; wound careGanapathy et al [], 2017United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=40; caregivers—intervention: n=40Cirrhosis and hepatic encephalopathyPatient BuddyMobile appEnhancing caregiver preparedness; enhancing caregiver knowledge and skills; enhancing patient-provider communication; monitoring pulse, oxygen, HR, BP, and weight at home; enhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; delirium screening and management; fall prevention; medication management; entering grams of sodium consumed; assessing cognition (EncephalApp); Timed Up and Go testGollish et al [], 2019CanadaFeasibility (pilot) study; qualitative studyCommunity, home, or retirement homePatients—intervention: n=629Total hip replacement and knee arthroplastymyHip&KneeMobile appEnhancing patient-provider communication; increasing self-care; detecting any postoperative issues; encouraging lifestyle changes; improving symptom management; medication management; pain control or managementGunter et al [], 2018United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=40Vascular surgeryWoundCheckMobile appAbility to identify symptoms of poor wound healing; detecting any postoperative issues; improving symptom management; wound careHabib et al [], 2021CanadaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=23; control: n=26All health conditionsSAMlMobile appMedication management; promoting adherence to medicationHägglund et al [], 2015SwedenRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=32; control: n=40HFHome intervention system (OPTILOGGm)Web app and monitoring devicesEnhancing patient-provider communication; enhancing patients’ knowledge, skills, and confidence; improving patient understanding; increasing self-care; improving symptom managementHeiney et al [], 2020United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=12HFHealthy HeartMobile appEnhancing patient-provider communication; monitoring pulse, oxygen, HR, BP, and weight at home; ability to identify symptoms of HF; enhancing patients’ knowledge, skills, and confidence; encouraging lifestyle changes; medication management; managing emotional changes; improving quality of lifeHeuser et al [], 2021CanadaRetrospective cohort studyCommunity, home, or retirement homePatients—intervention: n=396; control: n=458Obesity and bariatric surgerySeamlessMDMobile appManaging mood and anxiety; enhancing patients’ knowledge, skills, and confidence; increasing self-care; improving physical activity; encouraging lifestyle changes; improving symptom management; medication management; nutrition support; wound careHeyworth et al [], 2014United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=60All health conditionsSMMRTnWeb appMedication managementHighland et al [], 2019United StatesFeasibility (pilot) study; randomized controlled trialCommunity, home, or retirement homePatients—intervention: n=24; control: n=26Peripheral nerve block affecting one or more of the limbsmCare systemMobile appDetecting any postoperative issues; assessing patients’ needsHolzer et al [], 2022United StatesFeasibility (pilot) studyCommunity, home, or retirement home, rehabilitation, long-term care and nursing home (24-hour care)Patients—intervention: n=89; control: n=128Acute venous thromboembolismHealthFloMobile appEnhancing patient-provider communication; enhancing patients’ knowledge, skills, and confidence; medication managementHouchen-Wolloff et al [], 2021United KingdomFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=100Chronic obstructive pulmonary diseaseSPACEo for chronic obstructive pulmonary diseaseWeb appEnhancing patient-provider communication; improving patient understanding; increasing self-care; improving physical activityİlaslan and Özer [], 2022TurkeyRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=32; control: n=32Congestive HFWeb app for training and telephone follow-up for patients with HFWeb appAbility to identify symptoms of HF; improving symptom management; meeting the informational needs of patientsIndraratna et al [], 2022AustraliaFeasibility (pilot) study; randomized controlled trialCommunity, home, or retirement homePatients—intervention: n=81; control: n=83Cardiac diseaseTeleClinical CareMobile app and wearable deviceMonitoring pulse, oxygen, HR, BP, and weight at homeJohnson et al [], 2022United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=16; control: n=15Decompensated HFHF-SMARTpWeb appAbility to identify symptoms of HF; enhancing patients’ knowledge, skills, and confidence; improving patient understanding; encouraging lifestyle changes; improving symptom management; improving quality of lifeKang et al [], 2022AustraliaFeasibility (pilot) study; randomized controlled trialCommunity, home, or retirement homePatients—intervention: n=43; control: n=42General surgeryWeb-based discharge education programWeb appIncreasing self-careKargar et al [], 2020IranRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=30; control: n=30BurnsSelf-care educational mobile app for burnsMobile app and web appImproving quality of lifeKeng et al [], 2020CanadaCross-sectional studyCommunity, home, or retirement homePatients—intervention: n=106Colorectal surgeryHome to Stay digital program after colorectal surgeryMobile appMonitoring patient recovery at homeKersey et al [], 2022United StatesFeasibility (pilot) study; randomized controlled trialCommunity, home, or retirement homePatients—intervention: n=16; control: n=15StrokemHealth platform for strategy training in inpatient stroke rehabilitation (iADAPTq)Mobile appAssessing the feasibility of inpatient stroke rehabilitationKhan et al [], 2018DenmarkMixed methods studyCommunity, home, or retirement homePatients—intervention: n=33Cardiac surgeryActiveheart portalWeb appNot reportedKhanwalkar et al [], 2019United StatesCase-controlCommunity, home, or retirement homePatients—intervention: n=208Septosplasty and endoscopic sinus surgeryDPEr platformMobile appDetecting any postoperative issues; pain control or management; PROs; monitoring pain; collecting data on the postoperative day when the patient returned to workKim et al [], 2016United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=13Knee arthroplastyiGBs programMobile appEnhancing patients’ knowledge, skills, and confidence; increasing self-care; detecting any postoperative issues; improving physical activity; encouraging lifestyle changes; rehabilitation (physical therapy and occupational therapy); improving quality of lifeKnapp et al [], 2021United StatesQuantified patient engagementCommunity, home, or retirement homePatients—intervention: n=207Total hip replacement and knee arthroplastyPeerWellMobile app, web app, and SMS text messagingPromoting mental well-being; enhancing patients’ knowledge, skills, and confidence; improving physical activity; nutrition support; rehabilitation (physical therapy and occupational therapy); improving quality of lifeKooij et al [], 2021The NetherlandsFeasibility (pilot) study; mixed methods studyCommunity, home, or retirement homePatients: n=39Chronic obstructive pulmonary diseaseSelf-management app for high-risk patients with chronic obstructive pulmonary diseaseMobile appIncreasing self-care; improving symptom management; medication managementKristjánsdóttir et al [], 2013NorwayRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=48; control: n=64Chronic widespread painSmartphone-based intervention for chronic widespread painMobile app and web appPromoting self-management of chronic painKummerow et al [], 2015United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=50General surgeryMHAVtWeb appEnhancing patient-provider communication; improving symptom management; assessing patients’ needs; wound careLayton et al [], 2014United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=16Coronary artery disease and congestive HFSmartphone-based app to monitor outpatient discharge instructions of patients with cardiac diseaseMobile appEnhancing patient-provider communication; improving patient understanding; increasing self-care; follow-up appointments with primary care provider; medication management; encouraging activityLee et al [], 2022CanadaFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=70; control: n=35Colorectal surgeryMobile app follow-up for same-day dischargeMobile appDetecting any postoperative issues; pain control or managementLee et al [], 2022CanadaCohort studyCommunity, home, or retirement homePatients—intervention: n=48; control: n=73Colorectal surgerymHealth remote postdischarge monitoringMobile appEnhancing patient-provider communication; improving symptom management; assessing rates of complicationsLiu et al [], 2021ChinaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=49; control: n=49Spinal cord injuryTogetherMobile appEnhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; follow-up appointments with primary care provider; improving quality of lifeLi et al [], 2022ChinaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=143; control: n=147Coronary artery diseaseDTxuMobile appMonitoring pulse, oxygen, HR, BP, and weight at home; enhancing patients’ knowledge, skills, and confidence; encouraging lifestyle changes; improving symptom management; medication managementLou et al [], 2022ChinaQuasi-experimental studyCommunity, home, or retirement homePatients—intervention: n=101; control: n=60Not reportedmVSv intervention to enhance spiritual well-beingMobile appFostering spiritual well-beingLyu et al [], 2021ChinaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=58; control: n=58Diabetes (type 2)Nurse-led web-based transitional care programWeb appIncreasing self-care; fostering treatment adherence; improving quality of lifeMaría Gómez et al [], 2022ColombiaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=39; control: n=42Diabetes (type 2)mHealth app for patients with type 2 diabetesMobile app and web appManaging glycemic controlMarvel et al [], 2021United StatesNonrandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=200; control: n=864Acute myocardial infarctionAcute myocardial infarction DHIMobile app and wearable deviceEnhancing patient-provider communication; monitoring pulse, oxygen, HR, BP, and weight at home; increasing self-care; follow-up appointments with primary care provider; medication managementMetilda et al [], 2021IndiaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=50; control: n=50Brain injuryAimeoMobile appEnhancing patient-provider communication; enhancing patients’ knowledge, skills, and confidence; detect any postoperative issuesPark et al [], 2019United StatesFeasibility and adoptability studyCommunity, home, or retirement homePatients—intervention: n=58Congestive HFDigital health monitoring for patients with HFMobile app and web appAbility to identify symptoms of HF; increasing self-care; improving symptom managementParuchuri et al [], 2021United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=118; control: n=343Coronary artery diseaseWellframeMobile appEnhancing patients’ knowledge, skills, and confidence; encouraging lifestyle changes; improving symptom management; improving quality of lifePeng et al [], 2022ChinaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=47; control: n=47Hepato-pancreato-biliary surgery and biliary tract diseaseMobile continuous nursing platformMobile appEnhancing caregiver knowledge and skills; enhancing patient-provider communication; ability to identify symptoms of poor wound healing; enhancing patients’ knowledge, skills, and confidence; improving caregiver understanding; detecting any postoperative issues; assessing patients’ needs; medication management; managing emotional changes; nutrition support; improving quality of life; wound care; T-tube placement and fixation method; observation of bile-related traits; treatment method of T-tube slippage; selection, fixation, or replacement of drainage bagPickens et al [], 2019United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=122Hepato-pancreato-biliary surgerySeamlessMDMobile appManaging mood and anxiety; enhancing patients’ knowledge, skills, and confidence; detecting any postoperative issues; improving physical activity; improving symptom management; nutrition support; improving quality of life; collecting PROsPonder et al [], 2020United StatesDescriptive study; feasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=47Spinal cord injurySmartphone app with a digital care pathway for patients undergoing spine surgeryMobile app and web appImproving patient engagement; facilitating shared decision-making between patients and caregiversPooni et al [], 2022CanadaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=128; control: n=125Colorectal surgeryPostdischarge Home to Stay mobile appMobile app and web appAbility to identify symptoms of poor wound healing; improving patient understanding; detecting any postoperative issuesPronk et al [], 2020The NetherlandsRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=38; control: n=33Knee arthroplastyPainCoach appMobile appMedication management; pain control or management; rehabilitation (physical therapy and occupational therapy)Pugliese et al [], 2019CanadaFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=30StrokeRecoverNowMobile appEnhancing patient-provider communication; rehabilitation (physical therapy and occupational therapy)Reid et al [], 2012CanadaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=115; control: n=118Cardiac diseaseCardioFit internet-based expert systemWeb appImproving physical activityRequena et al [], 2019Spain2-arm open-label nonrandomized studyCommunity, home, or retirement homePatients—intervention: n=107; control: n=52StrokeFARMALARMMobile appEnhancing patient-provider communication; enhancing patients’ knowledge, skills, and confidence; improving physical activity; medication management; controlling vascular risk factorsRian et al [], 2022NorwayRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=134Knee arthroplastyEir (Eir Solutions AS)Web appEnhancing patient-provider communication; detecting any postoperative issues; medication managementRosner et al [], 2018CanadaCohort studyCommunity, home, or retirement homePatients—intervention: n=371Orthopedic fracture (any)Internet-based orthopedic patient self-reports of postdischarge complicationsMobile appEnhancing patient-provider communication; improving symptom management; assessing rates of complicationsSaunders et al [], 2021AustraliaRandomized controlled trialCommunity, home, or retirement homePatients—intervention: n=50; control: n=49Hip osteoarthritisMy Hip JourneyWeb app and email remindersEnhancing caregiver preparedness; enhancing patient-provider communication; enhancing patients’ knowledge, skills, and confidence; improving patient understanding; increasing self-care; improving physical activity; encouraging lifestyle changes; improving quality of lifeSchenkel et al [], 2020United StatesFeasibility (pilot) studyCommunity, home, or retirement homePatients—intervention: n=28; control: n=28Lung transplantationActiCareWeb appEnhancing caregiver knowledge and skills; enhancing patient-provider communication; monitoring pulse, oxygen, HR, BP, and weight at home; enhancing patients’ knowledge, skills, and confidence; increasing self-care; detecting any postoperative issues; encouraging lifestyle changes; medication management; nutrition support; rehabilitation (physical therapy and occupational therapy); tracking appointmentsScheper et al [], 2019The NetherlandsCohort studyCommunity, home, or retirement homePatients—intervention: n=69Total hip replacement and knee arthroplastyWoundcareMobile appEnhancing patient-provider communication; ability to identify symptoms of poor wound healing; detecting any postoperative issues; pain control or management; wound care; prevention of prosthetic joint infectionSchneider and Howard [], 2017United StatesDescriptive studyCommunity, home, or retirement homePatients—intervention: n=44; control: n=42StrokeTechnology-improved coping for patients after strokeMobile appImproving patient understanding; improving symptom management; follow-up appointments with primary care provider; medication management; managing emotional changesSchubart [], 2012United States