• Research

    Instead of health care, how about “well care”?

community wellness activity
Photo was taken prior to COVID-19 pandemic and masking recommendations.

Recent Mayo Clinic research showed that it is possible to electronically connect community health and wellness program information with people's medical records in a reliable and secure manner. The combined data can help patients and their doctors identify promising programs that may help patients reach their health and wellness goals.

The linkage can also provide valuable health outcome information to community programs, providing necessary evidence to support continuing, stopping or expanding a particular initiative.

Published in Learning Health Systems, the study describes how the investigators implemented and evaluated the various components of this novel, learning "well care" system.

Paul Takahashi, M.D.

"Hospitals and health care centers have a moral responsibility to do more in their communities than just treat patients with an illness or injury," says Paul Takahashi, M.D., a community internal medicine physician at Mayo Clinic and the senior author of the study. "We also need to collaborate within the community on collective efforts to improve the quality of life, health and wellbeing of all."

"It's a new way of thinking for some health care providers and organizations," he says, "the idea that a substantial focus among those who practice of medicine should be on lessening the need for our services."

The recent study is an example of this type of community collaboration, conducted with the intention of expanding the community's capability to work together for improved population health and wellness.

Collaborating for better community outcomes

A variety of evidence-based health and wellness programs have been developed around the world. They have been tested with randomized controlled trials, and found to improve individual participant outcomes, but little is known about how well they work when offered in a natural community setting.

Sarah Redmond, Ph.D.

"Our pragmatic evaluation of the effectiveness of evidence-based programs delivered in community settings, outside of a research context, is novel but crucial to understanding how these programs work in real world environments," says Sarah Redmond, Ph.D., the study's first author. Dr. Redmond is a health services researcher in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

"This work will lead to iterative learning for both the community programs and the health care systems in the community," she says. "This provides continuous improvement opportunities for the collaborators, and ideally will result in improved health and wellness for all members of the community."

The research team had some unique resources available in and around Rochester, Minnesota, where they conducted the study. In particular, the Rochester Epidemiology Project, which links medical records for most of the community, and WellConnect, which offers a number of wellness programs which have been proven to help improve health and quality of life.

Unique Resources

Read about the unique resources that this Rochester, Minnesota-based team was able to use to implement and evaluate their idea to advance "well care."

The Rochester Epidemiology Project, also called the REP — said 'rep' — is a community collaboration centered in Olmsted County, Minnesota. The REP has existed for more than 50 years, and links medical records from across 27 counties in Minnesota and Wisconsin, enabling a wide variety of medical research.

"The Rochester Epidemiology Project is really important because it is truly a snapshot of health and illness within our region," says Dr. Takahashi. "The amount of information that we gather is tremendous, and it helps us learn and grow our community's opportunities to be well and live fully."

"Thousands of papers and countless advancements have been enabled by the REP," he notes.

WellConnect is a newer collaboration overlapping the Southeast Minnesota portion of the REP's community. Currently WellConnect encompasses programs and participants in 11 counties, led by more than 20 organizations who work together to improve community health and wellness.

"We are always trying to work closer with community programs to help ensure wellness in our community," says Dr. Takahashi, about himself and his fellow health care providers.

He notes that working with WellConnect allows them reach community members with some of the highest risks for reduced quality of life and poor health outcomes. These include people with cognitive issues and older adults with multiple chronic health concerns. 

"We hope WellConnect will continue to be a valuable partner with us as we seek to improve our community's overall health and wellness," he says.

On the generalizability of their findings for other communities, Dr. Redmond encourages those communities with limited access to population-wide medical records.

"We recognize the uniqueness of the Rochester Epidemiology Project platform and know that it could prove time consuming and costly to replicate where a similar infrastructure does not exist," says Dr. Redmond. "Nonetheless, such an investment could add value. If we are able to connect community-based experiences with health outcomes, we gain a more complete understanding of how activities outside of the health care setting impact health. 

The team was able to obtain consent to share attendance information from 737 participants in one of three WellConnect programs — falls prevention, chronic disease management and pain management. Of these, they were able to link the information to medical records for 572 patients. They compared outcomes for participants against a cohort of twice as many nonparticipants who had similar personal characteristics to the WellConnect group.

They were able to make some observations about the real-world success of the individual programs in improving wellness among participants. However, the real value of the study came in what they learned about the infrastructure being piloted and observations they gathered about how to mature this into true community-based, participatory research.

Learning while improving

"As a proof of concept, we were successful in using our novel online infrastructure to connect community-based participation in evidence-based programs to health outcomes documented in the medical record, suggesting this may be a viable method for unobtrusively learning the effectiveness of community-based programs," says Dr. Redmond.

Additionally, the team identified several items to investigate in future iterations, including:

  • The consent process, including how the option is communicated, and how documentation is collected.
  • How and where adverse events or positive outcomes are collected and recorded for individuals.
  • Community program preparedness to obtain consent and ensure complete and timely participant data is entered into the system.
  • Communication and feedback strategies to ensure all stakeholders understand the value they will add and receive.

This research was conducted by the Mayo Clinic Kern Center for the Science of Health Care Delivery and the Division of Community Internal Medicine. Additionally, it was made possible by Mayo Clinic's Center for Clinical and Translational Studies. Dr. Takahashi is an alumnus of two scholar programs in the latter center and takes advantage of its infrastructure and programming to pursue ongoing clinical research interests.  

WellConnect and the idea of building a learning "well care" system were championed by Aaron Leppin, M.D., an implementation scientist at Mayo Clinic, who merged several unique perspectives — medical training, living as an active and engaged community member, and his personal experience with the health care system, which he shares in his TEDx talk.


Dr. Leppin passed away Nov. 3, 2021, leaving a legacy that includes this work.

"Dr. Leppin worked tirelessly on promoting health equity through a number of implementation projects," says Dr. Redmond. "Most notably, he was committed to helping create a learning "well care" system to actively promote health and wellbeing in the community and address health disparities. We plan to continue to advance his ideas."

Dr. Leppin was not alone in his efforts.

"Helping to ensure health is a community commitment," says Dr. Takahashi. "We all have a role, and I am really thankful we live in a community that invests in wellness and independence for all."


Related Articles