The Population Health Department on the UAB Huntsville Regional Medical Campus enhances patient care and resident learning by focusing on prevention, care coordination, and chronic disease management. Serving as a vital bridge within the healthcare system, the department helps ensure that patients do not fall through gaps in care.
Established in 2018, the department is led by Mary Rozier-Hachen, BSN, RN, population health nurse coordinator at UAB Huntsville. Its care team, comprising of physicians, residents, pharmacists, medical assistants, and a social worker, works collaboratively to support Medicare and Medicare Advantage patients, ensuring they receive the preventive care and follow-up services covered by their plans.
A major focus of the department’s clinical work is conducting annual wellness visits, which help identify preventive care needs, review health risks, reconcile medications, and address potential issues before they become more serious. The department conducts approximately two thousand of these visits each year, contributing to earlier detection of treatable conditions and improved patient outcomes.
“Our residents graduate better prepared because they understand how population health, preventive services, and transitional care fit into everyday practice—improving care for patients while also supporting financially sustainable practice models after graduation,” said Roger Smalligan, M.D., MPH, regional dean of the Huntsville Regional Medical Campus.
The department plays an especially important role in resident education on the Huntsville campus. Incoming residents receive an introduction to the Population Health Department, with training focused on annual wellness visits and Hierarchical Condition Category (HCC) coding. Family Medicine residents meet with the department annually throughout all three years of training, while Internal Medicine residents receive an overview early in residency and receive additional support in the clinic as needed. “This training helps residents understand preventive care workflows, documentation expectations, and the coding practices they will rely on in future practice,” said Rozier-Hachen.
Residents also gain exposure to team-based care through their work with the department. In addition to addressing clinical needs, they learn to recognize the barriers that may affect a patient’s health, including transportation challenges and difficulty managing chronic conditions at home. Over the years, residents have increasingly involved the department in patient care, making population health an integrated and trusted part of residency training on the Huntsville campus.
The department further supports residents by teaching them about transitional care. This includes follow-up after hospital discharge to confirm medications, identify equipment or support needs, and reconnect patients with outpatient care. To support this process, the department provides follow-up calls to patients. “Taking that extra step with the patient and making that phone call to ensure everything is okay can really prevent problems down the road,” said Rozier-Hachen.
Beyond resident education, the department, along with the residents and faculty, identify eligible Medicare patients who would benefit from chronic care management with two or more long-term conditions. These patients are referred to a partnering agency who provide monthly phone outreach, medication review, appointment reminders, and coordination of services such as therapy or medical equipment, helping patients stay connected to care between visits.
Together, these efforts strengthen preventive care, improve care coordination, and give residents meaningful, hands-on experience in team-based medicine, preparing them for the realities of modern clinical practice.