Integrating Research, Health Care, and Community at Scale to Address the Population Health Question

Am J Manag Care. 2025;31(Spec. No. 10):SP721-SP723. https://doi.org/10.37765/ajmc.2025.89798

As strong proponents of continuous learning systems,¹ we commend the superb work published in this issue of Population Health, Equity & Outcomes, especially for centering the research on an expressed need within a learning health care community.² The research is built on decades of relationships and collaborations with deep foundations of trust, as illustrated by a public health practitioner contacting a researcher for assistance with a difficult question. However, one can argue that they are sliding past a critical, wickedly complex issue of trials and practice in the milieu of “Minnesota nice” antecedents, even referring to their work as a “unique collaboration,”² begging the question of its generalizability. Also, the timing of the receipt of Patient-Centered Outcomes Research Institute (PCORI) funding is quite fortuitous and may not apply to similar projects.

However, this Minnesota Care Coordination Effectiveness Study (MNCARES) has proven its worth with a base in primary care, which is crucial for making health care affordable and producing excellent outcomes. Several articles describe MNCARES’ findings, including that integrated social workers are more likely to make assessments for social services and are more involved with referrals.³

We argue that moving from health care to health learning communities is key and requires collaboration that includes research, health care, and increased community participation and perspective. Reflecting on the aftermath of Hurricane Katrina, Karen DeSalvo, MD, who was the New Orleans, Louisiana, health commissioner from 2011 until 2014, wrote, “Along the way, we also learned a larger lesson: Although health care is necessary, it is not sufficient to create a healthy community. In New Orleans, we stopped treating patients and started treating community members.”⁴ The polarities of health care and health, and patients and community members, are challenging but foundational.⁵ Individual patients and geographic populations are 2 different things, but if they are held in appropriate tension with trusted researchers and collaborators, we believe they can produce creativity, learning, and action for all involved.

Many of the strategies used by Solberg et al² can dovetail with the expansion from a health care learning community to a health learning community, or an Accountable Communities for Health (ACH) structure. ACH approaches, known by multiple names, are “multisector, community-based partnerships that bring together health care, public health, social services, other local partners, and residents to address the unmet health and social needs of the individuals and communities they serve.”⁶ Mittmann et al used multiple examples to acknowledge the challenges of evaluating “agents of change” and financial models for addressing upstream factors.⁶ Identifying the investments needed in the multiple determinants of health over the life course is what one of us (D.K.) calls “the overriding population health question” for maximizing health outcomes and minimizing inequities.⁷ Although PCORI funding did not allow the Minnesota researchers to look at costs or investments, this could be an area for future research.

Using the ReThink Health Dynamics Model, Homer et al explored how communities can consider their investments to enhance the performance of health systems and make them affordable.⁸ As noted in their analysis, a health learning community can review care coordination as part of a suite of higher-value care with multiple critical components, including care coordinators. Homer and colleagues proposed 3 other ways to enhance performance and financial stability: reinvest savings and global payments, encourage healthier behaviors, and increase socioeconomic opportunities. Failing to invest savings from higher-value care coordination and other activities results in minimal long-term performance gains and affordability for the health system. This also relates to the nexus between allocating and reallocating resources for population health.⁹

The research described by Solberg et al would not have happened without leadership and funding from the federal government. We live in a terrifying environment, facing challenges of funding cuts that could threaten support for integrating research, learning, and health at the regional, state, and local levels.¹⁰ Such cuts would be penny-wise and pound-foolish. Hopefully, research integrated into communities can continue, as detailed in the article by Rhodes et al,¹¹ “AHRQ’s Healthcare Extension Service—State-Based Solutions to Health Care Improvement,” and address investment issues.

No one can confidently say at this point how far and to what end artificial intelligence will go in health care and health. But if there is ever a bright prognosis, promoting a learning health community is one.¹²

We agree with the authors’ research and the referenced New England Journal of Medicine article¹³ that there is a house divided between the knowledge generation in clinical trials and implementation in the health care delivery enterprise, but also probably in the health learning community. We need to repair and integrate not just a house divided between research and health care, but a house divided among research, health care, and the multisector health community. By doing so, we could address the population health question.

Author Affiliations: HealthPartners Institute (SJM), Minneapolis, MN; independent health policy consultant (PH-C), Ann Arbor, MI; University of Wisconsin-Madison (DK), Madison, WI.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SJM, PH-C, DK); analysis and interpretation of data (DK); drafting of the manuscript (SJM, PH-C); critical revision of the manuscript for important intellectual content (SJM, PH-C, DK); and administrative, technical, or logistic support (SJM).

Send Correspondence to: Paul Hughes-Cromwick, MA, CBE, 5053 Doral Dr, Ann Arbor, MI 48108. Email: phughescromwick@gmail.com.

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