By Heather Crow, MSHA, MBA
In the heart of North Alabama, UAB Medicine: Huntsville Regional Medical Campus stands as a beacon of innovation, education, and compassionate care. As an extension of the University of Alabama at Birmingham’s medical system, the Huntsville campus plays a vital role in training future physicians while delivering high-quality care to the community. With a strong emphasis on primary care, the campus not only educates medical students and residents but also serves as a critical access point for patients across the region. Among its many forward-thinking initiatives, one program in particular has emerged as a transformative force in patient care: The Population Health Team.
Meet the Population Health Team: Led by Experience, Driven by Compassion
Formed in 2018, the Population Health Team is led by Mary Rozier-Hachen, BSN-RN, who has over 33 years of healthcare experience. Rozier-Hachen and her group of skilled medical assistants work in close collaboration with physicians, residents, pharmacists, and a social worker to create an interdisciplinary care model.
The Population Health Team’s mission is to close care gaps and provide comprehensive support to patients, particularly those in vulnerable populations. Many of the individuals served by the team face challenges related to age, socioeconomic status, or chronic health conditions. These patients often require more than a standard 15-minute appointment—they need time, education, and a personalized approach to care.
Patients who qualify for chronic care management are invited to join the program where they receive tailored support. The team presents evidence-based options and empowers patients to make informed decisions about their treatment plans. Rozier-Hachen connects with patients on a personal level, explaining how disease impacts daily life and guiding them through complex health decisions.
Bridging the Gap: Why Population Health Matters
In today’s healthcare landscape, physicians are often stretched thin. Appointments are short, patient needs are complex, and the system can feel overwhelming. The Population Health Team acts as a bridge to fill in the gaps that traditional care models may leave behind. By working together across disciplines, the team ensures that no patient falls through the cracks.
This collaborative approach is critical for patients with low health literacy. Understanding medical terminology, navigating insurance, and adhering to treatment plans can be daunting. Rozier-Hachen and her team take time to educate patients, whether it’s explaining the importance of A1C monitoring for diabetes or walking a patient through the steps of a colon cancer screening.
The results speak for themselves. Each year, the team conducts approximately 2,000 annual wellness visits. These visits are more than routine checkups. They’re opportunities to assess risk, catch issues early, and build relationships that lead to better long-term outcomes.
The ACO Advantage: Better Care, Smarter Systems
UAB Huntsville’s Population Health Team is also a proud part of the Huntsville Hospital Accountable Care Organization (ACO), a partnership that enhances care coordination and reduces unnecessary healthcare costs. Being part of an ACO means that the team can offer patients a wide range of preventive services—such as the in-house retinal imaging camera, IRIS, Cologuard testing for colorectal cancer, and regular A1C monitoring—while also minimizing duplication of efforts and avoiding redundant hospital admissions.
This model is a win-win. Patients receive proactive, personalized care that keeps them healthier and out of the hospital, while providers benefit from streamlined communication and shared goals. The ACO framework supports the Population Health Team’s mission by aligning incentives around quality, not quantity.
Real Impact: Stories from the Field
Consider the case of a patient with uncontrolled diabetes, limited transportation, and low health literacy. In a traditional setting, this patient might struggle to manage their condition, leading to frequent ER visits and poor outcomes. But under the care of the Population Health Team, the story changes.
Team begins by scheduling a wellness visit, during which they assess the patient’s needs and barriers. They coordinate with the social worker to address transportation issues, consult with the pharmacist to optimize medication management, and provide one-on-one education about diet and glucose monitoring. The patient is given tools, support, and a clear path forward. Over time, their A1C levels improve, hospital visits decrease, and their confidence in managing their health grows.
This is just one example of the countless lives touched by the Population Health Team. Each patient is treated as a whole person, not just a diagnosis.
Looking Ahead: Expanding the Vision of Population Health
Rozier-Hachen’s vision for the Population Health Team includes expanding its reach and resources to identify patient needs even before an official diagnosis is made. For example, if a patient’s blood pressure has been consistently elevated over several visits, the team could intervene early—educating the patient, coordinating care, and potentially preventing the onset of hypertension.
This forward-thinking mindset is echoed by Shivani Malhotra, MD, Chair of Family Medicine at UAB Huntsville, who shares:
“Our population health team has truly made a difference. Through proactive outreach, thoughtful coordination, and smart use of data, they’ve not only improved outcomes but also strengthened our ACO performance—allowing us to deliver care that’s more connected, compassionate, and cost-effective. What makes this team stand out even more is how genuinely personable they are—patients feel seen, heard, and cared for in every interaction.”
Malhotra’s words highlight the heart of the program: a team that blends clinical excellence with human connection. As Mary and her colleagues continue to grow and innovate, their work will remain a cornerstone of UAB Huntsville’s commitment to community health.
The Population Health Team is more than a program—it’s a philosophy. It’s about recognizing that health is not just about lab results or prescriptions; it’s about understanding, support, and the belief that every patient deserves a chance to thrive.
Heather Crow, MSHA, MBA is the Director of the Office of Family Health Education & Research at UAB Medicine.
