Several of the following chapters of this textbook draw from this case study. This case describes the efforts of healthcare professionals to develop and implement the Seniors Program.^[1] The following sections present an overview of this program, describing what it was, identifying key dates, and discussing significant events during its life cycle. This chapter presents a highly abridged summary of the case. If you wish to learn more, you can find the full details in the book, Values, Rationality, and Power: Developing Organizational Wisdom.

The Seniors Program: A Case Study

In 2013, a British Columbia (BC) health authority entered into a collaboration with a second health authority in Nova Scotia (NS) and a non-profit foundation (herein named the Foundation). The purpose of this collaboration was to develop an intervention to delay the onset of frailty in healthy but at-risk senior citizens. This intervention became known as the Seniors Program.

What was the Seniors Program?

The Seniors Program was a collaborative study aimed at determining whether physical activity prevented frailty in the elderly. Physicians assessed patients using a frailty scale. Doctors identified patients who were healthy but at risk for frailty and recruited them to the program.

Participation in the program required patients to connect with community coaches. These coaches met with these senior citizens, discussed lifestyle goals and their current health status. Coaches then developed a physical activity plan for each senior. Initially, coaches would check in with their clients weekly to monitor progress and adjust their plan as needed. After several weeks, these check-ins reduced from weekly to monthly.

After six months, the physician would recheck the patient’s frailty. Results demonstrated that patients’ frailty scores improved from their participation in the program.

The Organizational Structure of the Seniors Program

Three organizations collaborated in the Seniors Program’s development: the BC Health Authority, NS Health Authority, and the Foundation. The Foundation ran a Training Fellowship that instructed healthcare administrators on how to apply evidence to the practice of running a healthcare system. Both the BC and NS Health Authorities sent administrators to this Training Fellowship. It was through this fellowship that these individuals developed and implemented the Seniors Program.

Seniors Program timeline

The Seniors Program transpired over several years. We can divide this timeline into several stages based on the activities performed. These stages include the following, which subsequent sections describe in more detail.

• Assembling the Training Fellowship
• Seniors Program Development
• Seniors Program Implementation
• Wrap Up
• After the Training Fellowship

Assembling the Training Fellowship (Ended December 2013)

During this stage, the CEO of the BC Health Authority contemplated different ways to deal with the strain an aging population was having on the Canadian healthcare system. To this end, he developed innovation centers and hosted meetings between experts from various health authorities to discuss possible solutions. The result of this process was the decision of the BC and Nova Scotia Health Authorities to partner with the Foundation in December 2013. To this end, both health authorities sent staff to participate in the Training Fellowship. The details of this collaboration were documented in a Project Charter, which was an agreement all participating organizations signed.

Seniors Program Development (December 2013 to November 2014)

Members of the Training Fellowship performed literature reviews on the latest science of aging. Their goal was to learn everything researchers in the field knew about delaying frailty. As this stage progressed, the fellowship met with experts to learn first-hand how the field was advancing. They met with seniors groups to understand the needs and desires of the population they wanted to help as well as selecting the coaching organization with which they wanted to work.

Initially, the fellowship aspired to create a single intervention that both the BC and NS health authorities would implement. They wanted to find the “one best way” to prevent frailty. During the development stage, though, they discovered differences between the regions that undermined this desire. Patient demographics varied between the two health authorities, as was the organization of healthcare infrastructure. Thus, each region had to adjust the Seniors Program for the specifics of their local context.

Likewise, the Seniors Program sought to use physical activity as the means through which it delayed frailty in the elderly. The research they performed had shown exercise was the best way to delay frailty’s onset. The research even prescribed a specific regimen of exercise called the Stanford Model (a name later changed to Chronic Disease Self Management). The health of participating seniors varied widely, however. Consequently, rather than apply the Stanford Model uniformly across all patients, the fellowship had to make individual adjustments.

During the development stage, the fellowship had to decide what to call the target patient. They scoured the scientific literature to identify what patient categories were used by physicians and researchers in the field. After much deliberations, they decided that, according to the scientific literature, the name “pre-frail seniors” was most applicable.

When they approached patient groups and proposed this name, however, seniors disliked it especially the use of the word “frail.” These people felt fine. They saw frailty as this horrible thing and were distressed to find that the medical establishment thought of them as “pre-frail.”

It was the responsibility of physicians to enroll patients in the Seniors Program. Doctors are trained in evidence-based medicine. They were, therefore, familiar with the scientific literature. To align with the physicians’ training, the fellowship chose to ignore the patients’ concerns and used the name “pre-frail seniors.”

The CEO of the BC Health Authority, who initiated the Seniors Program, resigned in June 2014. With his departure, the BC contingent of the fellowship lost its key executive champion. The risk existed that the BC Health Authority might cancel the project, but the fellowship managed to keep the Seniors Program alive.

By the end of this stage, the fellowship had developed the specific processes of the Seniors Program. In November 2014, the program enrolled its first patient.

Seniors Program Implementation (November 2014 to End of Summer 2015)

During this time, the Seniors Program enrolled fifty-one patients and monitored them for six months. The fellowship collected data from physicians and analyzed them. The results were encouraging. Participation in the Seniors Program improved patients’ frailty.

In January 2015, the BC Health Authority hired its new CEO. One of the many things he had to decide was what to do with the Seniors Program.

Wrap Up (End of Summer 2015 to October 2015)

The new CEO attended a symposium that the Foundation hosted. At this symposium, the training fellowship presented their results. This presentation was the final assignment of the training fellowship. With the fellowship concluded, the participating organizations had to decide whether to support the spread of the Seniors Program to other jurisdictions or to let the program die.

Though initially leery of spending the BC Health Authority’s resources on the Seniors Program, the new CEO found its results compelling. He decided to support the program’s spread within the BC Health Authority’s boundaries.

After the Training Fellowship (October 2015 to August 2017)

The collaboration between the BC and NS Health Authorities ended. Though members of the fellowship remain in contact, they no longer worked together officially. Several members of the BC contingent of the fellowship ceased working on the Seniors Program. Those members that remained struggled to spread the adoption of the Seniors Program model through the region administered by the BC Health Authority.

During this time, the CEO of the BC Health Authority supported attempts to spread the Seniors Program among clinics in its region. A major challenge was the lack of fee code that adequately compensated doctors for the work they would do administering the program. Faced with the financial pressures of running their clinics, many physicians were unable to adopt the program in the absence of adequate compensation.

In response, the BC Health Authority provided funding and personnel to clinics adopting the program. Additionally, the fellowship developed electronic documentation systems that automated much of the physicians’ work in an attempt to reduce the clinical costs of the program. They further educated doctors on related fee codes they could use to bill for their services. Despite these efforts, however, spread of the Seniors Program within the region was slower than the fellowship wished. Spread to other regions in Canada was even slower.