Population health expands the focus of health care from individual, in-person care to the proactive management of cohorts that can occur asynchronously from a clinical encounter. In its most successful form, the approach segments populations by defined characteristics and promotes outreach and engagement to deliver targeted interventions, even among those who have missed recent or routine care. The triple aim, supported by the Institutes for Health Care Improvement, emphasizes improving the health of populations, cost of care, and patient and care team experience and has influenced new approaches in primary care. In primary care settings such as community health centers, the goal of improving outcomes leverages technology to expand focus from point-of-care interventions to population-level approaches to deliver high-quality preventive services and chronic disease management that benefit entire families and communities. Developments in informatics have introduced technology tools for population management and underscored the need to align technology with effective processes and stakeholder engagement for success. Informed by a review of the literature and observations across multiple implementations of population health strategies in community health, in this conceptual paper, we describe the steps (process), domains of team expertise (people), and health information technology components (technology) that contribute to the success of a population health strategy. We also explore future opportunities to expand the reach and impact of population health through patient engagement, analytics, interventions to address social determinants of health, responses to emerging public health priorities, and prioritization-of-use cases by assessing community-specific needs.

Nearly half of people living with HIV in the U.S. are over age 50 and are navigating age-related changes while managing the complexities and challenges of HIV. People aging with HIV are an emerging community—it is imperative to understand the key issues faced by this community so to improve health outcomes and eliminate health disparities. This paper presents a CBPR approach by the SHARE board (a community advisory group comprised of older people living with HIV) and academic researchers. SHARE members conducted a mixed-methods needs assessment using a semi-structured interview guide they had developed, as well as a survey to determine community priorities for research, healthcare, and social services for people aging with HIV. SHARE members conducted 32 semi-structured interviews with individuals from across the country. From the 216 survey responses (mean age 55 years), 35% were Black, 30% were Hispanic, 50% were male, and 43% had been living with HIV for 11–15 years. 44% were fearful that long-term HIV medications will adversely affect them with aging. Triangulating interviews and surveys, financial strains and caregiving were primary age-related concerns. Affording medication and transportation were primary barriers to accessing healthcare. Most respondents had experienced stigma due to both age and HIV status. Respondents felt the most important areas for future research were optimizing management of multiple co-morbidities including HIV, and cognitive changes with HIV. Results from this community-led needs assessment identified key areas for interventions and research to address conditions disproportionately affecting the health of those aging with HIV.

With effective antiretroviral therapies, HIV has become a chronic disease. Currently, >50% of people living with HIV are 50+ years old, and they face dual challenges of aging and HIV management. Overall, <15% of published studies in HIV engage stakeholders in research. These rates are even lower for older adults with HIV. Thus, there is a critical need to engage long-term survivors in developing meaningful research questions for aging with HIV. To address this gap, we created the SHARE (Survivors of HIV Advocating for Research Engagement) board. Presenters will discuss the process for building the board’s research capacity and results of a community needs assessment that board members designed and conducted to ascertain priorities for HIV-aging research. Presenters will discuss evidence-based educational strategies utilized to build member research knowledge, and pre-post training changes in knowledge, confidence, and understanding. Presenters will focus on novel training approaches implemented in the remote environment.

The pivot to remote delivery of NCOA evidence-based programs has increased participant reach due to eliminating geographic or transportation barriers. Despite the convenience of participation in one’s own home, challenges for helping patients adhere to behavior change remain. This paper will present data from one community-based organization’s NCOA evidence-based falls prevention program implementation of Bingocize, Tai Chi, Otago, and SAIL on Zoom. Across all programs, only 36% of people who registered for workshops attended the first session. Participants, on average, only attended 27% of the sessions in a given workshop. To explore the barriers and facilitators to attendance in order to encourage patients to change health behavior, we used a mixed-methods approach to evaluate reasons for suboptimal adherence among n=735 participants across the 4 programs. We performed sub-group analysis to examine barriers and facilitators by the self-reported attendance rate. We conducted semi-structured interviews with n=14 participants, focusing on those who had less than 50% attendance for the workshop they registered for, and also received n=234 survey responses. For participants who attended >50% of workshop sessions, class enjoyment was the most cited facilitator of attendance. However, for those who attended < 50% of workshop sessions, email reminders were the most cited attendance facilitator. Results from this project provide critical information about specific barriers that different sub-groups of older adults face regarding participation in NCOA evidence-based programs to develop strategies to help motivate patients for health behavior change.