Using Aggregate Data on Health Goals, Not Disease Diagnoses, to Develop and Implement a Healthy Aging Group Education Series

Background: The Healthy Aging Group Education Series was developed by interprofessional primary healthcare team members and researchers to address the health needs and goals of nutrition, fitness and function, and advance care planning identified using data from a randomized controlled trial. Methods: Older adults from one family practice were invited to attend the series and participate in the descriptive evaluation. The series was developed based on aggregated patient-reported data on health goals, risks, and needs gathered using a structured process. Surveys which included open-ended feedback and rated items of content and delivery evaluated the series. Program delivery expenses were itemized. Results: Of 69 people invited, a range of 26 to 37 people attended sessions. The overall series was rated positively with respect to meeting attendees’ expectations and being well-organized; 69.2% and 76.9% of attendees gave a positive rating respectively. Individual session feedback indicated a range of positive ratings (82.8-100%) for categories of effective and engaging presenters and providing new and relevant information. The majority of attendees (76.9%) indicated they would recommend the series to friends. The series continues to be offered regularly in the family practice. Conclusion: The health goal information (and not disease diagnosis) that was used to develop and deliver the program resulted in a program that was well received by participants and sustainable in the family practice.


Introduction
Using aggregate data on health goals, not disease diagnoses, to develop and implement a healthy aging group education series Healthcare systems are not well designed to maintain or improve the health of individuals [1][2][3]. Much of our healthcare system uses processes that are reactive and not proactive or preventative [4]. People who may seem well or may not have an obvious morbidity can benefit from strategies to prevent decline. Creating health care delivery systems that focus on keeping people well will have benefits for individuals, communities and the overall healthcare system. The primary healthcare system is in need of novel care models that leverage interprofessional team members to provide alternatives to physiciancentred care. In diabetes care for example, alternative care models [5][6][7][8] have been explored as approaches outside of traditional physician-led visits [9]. Group medical visits, self-management education and group education have become increasingly popular. These approaches can improve efficiency and encourage patient self-management across a variety of patient groups [10][11][12][13][14][15][16][17][18][19][20][21].
The concept of leveraging aggregate data compliments the approach of delivering care to groups of patients with shared needs. Using such data to identify care gaps does not detract from individuality but rather adds another dimension, as individuals benefit from the guidelines developed for the populations to which they belong as well as the sharing of peer-to-peer experience that group visits are based upon [22]. Although group medical visits have been fairly common in delivering care across people with shared medical needs, this approach has been relatively limited to shared chronic disease diagnoses and is not necessarily focused on prevention nor on groups of patients who may be considered "well". Addressing patient priorities and goals effectively is increasingly a focus of discussion in primary care. Interprofessional primary care teams are well suited to rise to the challenge of identifying and responding to goals of well, yet at-risk, patients. Doing this in a cost-effective manner will be important. This program used aggregate health information and health goals to develop and implement a group educational series (Healthy Aging Group Education Series; Healthy AGES). It was developed with the intention that it could be adapted based on updated data.

Methods
The idea of the Healthy AGES organically emerged from the review of aggregate data from a study to evaluate the effectiveness of the Health TAPESTRY approach in partnership with the McMaster Family Health Team (MFHT). Health TAPESTRY is an approach that centres on meeting a person's health goals and health needs explicitly gathered with the support of technology, community volunteers, an interprofessional team, system navigation, and better links between primary care and community organizations [23]. The data on health goals indicated that participants wanted to stay or become physically active, stay socially connected, manage chronic conditions, stay at home, and improve dietary habits. The data on health needs and risks were also examined and showed that nutrition, fitness and function, and advance care planning (ACP) were areas identified as topics to be addressed (Table 1).  Key healthcare providers were invited to address the topics as working groups. The format agreed upon included an introductory session, then a 2-hour session for each topic, with one topic per week. Each session had learning objectives, an agenda, and activities. The introductory "teaser" session would review the concept of the series and be used to gather targeted information about the three topics from attendees. A survey was developed by the working groups and allowed attendees to indicate specific areas of interest for nutrition, fitness and function, and ACP. For each topic, attendees were also asked to list two questions they wanted to ask experts (Table 2 for intake questions and summary answers gathered for planning the series).  To meet individual patient needs, working groups were encouraged to use information from the intake survey prior to their session. The working groups were responsible to develop session content and any activities to foster learner engagement. A researcher was present in each working group to help maintain a unified focus around the series as a whole and bring the Health TAPESTRY perspective where necessary. Working groups met at least once in person, and then refined their session over email or informally in-person at the clinic.
The Health TAPESTRY research team was responsible for logistical considerations and costs of the series. The location of the series was Stonechurch Family Health Centre, a clinic within MFHT, which had free patient overflow parking (located about one block away from the clinic). A shuttle was available in anticipation of any mobility issues from the parking lot or poor weather. Hospitality ideas such as a registration table, an information package, signage, a greeter, refreshments, text size of handouts, and the use of a microphone were also considered. The series was developed in such a way to consider sustainability; it was flexible enough to address future areas of focus based on new, incoming aggregate data.

Evaluation
Rating of the overall event was completed as well as rating of how well each presentation provided relevant information, new information, and if the information was presented engagingly and effectively. Key messages attendees took away from the session were solicited. Informal feedback was solicited from the presenters. The cost of series and potential cost saving strategies were recorded. Research and program costs were separated.

Results
Invited individuals (N=69) were 70 years of age or older, community-dwelling and rostered within the MFHT who were the first group of intervention participants in the Health TAPESTRY study [23]; control participants were not invited so as not to interfere with the main study. Of the people invited, 26-37 people attend the sessions of the series. The average response rate to the invitation was 68%. Table 2 summarizes planning information of each session as well as identifies the interprofessional team members who comprised the working groups. A summary of information from implementation including attendance is shown in Table 2.
Notably, the learning objectives link to the results of the intake survey. The response rate to the evaluation form was 43% (teaser), 62% (nutrition), 75% (fitness/function), and 78% (ACP). The majority of attendees rated all aspects of the series positively (Figures 1 and 2). Commonly reported key messages included: the importance of eating proper food, sharing end-of-life desires with the one's circle of care, including their family doctor, and the need to keep moving. Attendees suggested running the series in retirement homes. Presenters suggested holding recurrent sessions, providing information about community programs related to the topics and noting that the series should be open to all seniors within MFHT, not only those in Health TAPESTRY.  Costs for developing and implementing Healthy AGES are shown in Figure 3. Research costs were $3,193.98. The total program cost for initial development and implementation was $7,126.72, with the majority of costs related to human resources. The cost estimate of a second offering of the same series was $5,788, assuming less development costs as well as considering one-time costs.
This type of program can be offered at a much lower cost by reducing or eliminating several items (i.e., shuttle service, pedometers, food/beverages, full-colour materials, fewer providers involved). We believe the series could still meet its objectives by having one family doctor, one registered dietitian, and one physiotherapist/occupational therapist involved. Considering all cost saving strategies, we estimate it would cost $1,025 per series offering.

Discussion
A healthcare approach using aggregate health information and health goals was used to develop and implement a group educational series. Overall, the series was perceived positively by both attendees and presenters. Strengths and challenges are discussed.

Strengths
Additional expertise was not required as development leveraged existing knowledge within the clinic. Secondly, bundling sessions together as "healthy aging" allowed multiple domains of aging to be addressed. Development was done in such a way that translated findings from a research study directly into clinical practice. Using the information from a large RCT to assess health goals and needs allowed for the identification of potential topics, then content of each session was augmented based on the intake survey, allowing for the series to address individual needs. It married findings from aggregate data with individual-based data collected at the first session. However, unlike other types of group care, health goal data (and not disease diagnoses) was used. This approach may push the healthcare system's focus on being proactive about health concerns, as well as group individuals based on function versus disease.

Positive by-products
Using aggregate data allowed for the identification of client needs that the clinic was either unaware of or had not systematically figured out how to address. Incontinence, for example, was one common health issue identified in the RCT, but it was decided not to initially include within the series. Identifying who and how to address the topics of nutrition, fitness and function and ACP was easier than identifying who and how to address incontinence in a group format. However, the process of developing the Healthy AGES was done in such a way to account for the addition of new topics. This process could also easily engage community leaders to address any topics that might be more efficiently addressed using resources outside the clinic walls.
Promoting sense of connection to the clinic was another positive by-product. Although not measured specifically, it is possible that

Challenges
To address the multidimensionality of healthy aging, a variety of disciplines was required. Ensuring the message was consistent across sessions was challenging albeit not impossible. Commitment from clinic leadership is essential to allow for time to develop the series and space to run the sessions. Also, finding a balance between population and individual care goals is difficult. Healthy AGES did not by any means replace the need for individual care but instead offered complementary care to a group of healthy seniors on topics that are often not addressed in usual clinical practice yet extremely important for health.
Our team found it challenging to "categorize" the Healthy AGES within the literature. A core feature of this program was education to target knowledge, akin to group education and group medical visits [12]. However, unlike group medical visits, medical assessments in any form were not completed. Part of the difficulty in categorizing Healthy AGES is that there is no standard approach to such group care models [12,19]. Perhaps all types of models have a purpose depending on the needs of the patients.

Limitations
Limitations to the evaluation design should be noted. Assessment of face validity of the surveys was done through team review; no other validation of the survey was completed. Further, no pre-measures of outcomes were measured, thus, the impact of the Health AGES on outcomes (i.e., knowledge, behaviour), including objective measures (i.e., body composition, muscle strength), is unknown. It should also be noted that the purpose of the study was not to determine effectiveness, but rather understand the process of developing a series using aggregate data on health goals and needs; thus, the sample size is small. Future research should include effectiveness measures, particularly those which are validated, to provide evidence of this type of care model and help to support the need for sustainability. A larger sample size as well as a comparison group are critical. In addition, modifying variables including learning style or cognitive capacity, may influence how an individual experiences the Health AGES.

Considerations for sustainability
Healthy AGES was a series developed and implemented as a partnership between the Health TAPESTRY research team and members of MFHT. Offering the series regularly requires the consideration of clinic resources and work flow. Working closely with the MFHT from the start allowed for such factors to be considered, however, some costs need to be reduced for the clinic to offer the Health AGES consistently. The goal was to develop the materials and a process to develop content in a way that was reproducible by the clinic and transferable to the clinic workflow. In essence, by handing over all materials and the process outline, the clinic could run the series on its own. Considering cost savings, we estimate that the Healthy AGES would cost approximately $1,025 per offering. This amount does not consider what the clinic could bill. Further, using aggregate health goal and need information requires a database that can be used by the clinic. This database was readily available because MFHT was a key implementation site for Health TAPERSTRY. With minimal support from the research team, MFHT is currently running Healthy AGES as an ongoing program, with an added topic of brain and bladder function, a sign of its potential sustainability.