Table 4. Challenges encountered, strategies implemented, and lessons learned during a pilot study of a multi-modal prehabilitation program in older surgical patients.

Activity	Challenges	Strategies Implemented	Lessons Learned
Screening and Enrollment	Screening at preoperative assessment visit (1-2 weeks before surgery) left limited time for intervention. Low initial referral volume. Recruiting patients with frailty	Moved screening upstream to surgical clinic appointments. Expanded number of participating clinics. Sent both email and in-person reminders to surgeons. Simplify eligibility criteria to reduce burden on referring surgeons.	Enroll from surgical clinics to ensure sufficient time for intervention. Outreach proactively and minimize workflow disruption for consistent referrals.
Intervention delivery and adherence	Transportation barriers limited attendance at in-person sessions. Technological issues (e.g., internet access or using virtual platforms) reduced adherence. Competing clinical demands interfered with participation. Physical limitations limited ability to engage. Some participants did not like the provided protein supplements. Lower adherence to meditation.	Provided free ride services and home-based physical therapy. Supplied tablets with cellular data for virtual sessions. Offered flexible scheduling and both in-home and virtual physical therapy options. Tailored exercises based on participants’ capability. Allowed choice of protein bar or drink and multiple flavors. Increased availability of meditation sessions and simplified virtual registration.	Individualize interventions based on participants’ health status and preferences. Reduce participation barrier by offering flexible scheduling and format options. Provide technological support and proactive feedback loops with interventionists.
Outcome follow-up and retention	Some participants did not respond to telephone follow-up interviews. Missed follow-up due to surgery cancellation.	Used multiple contact methods (e.g., email, telephone, mail-in survey)	Offer a choice of contact methods and modality. Continue follow-up even if surgery is cancelled. Consider remote monitoring and financial incentives.