Population Health

Population Health Care Model

The Population Health Care Model is a program focused on you – the patient – with a team-based care approach. Partnering with Carle Primary Care and Health Alliance^TM, you have access to team members who work closely with your doctor, nurses and medical assistants. They help you focus on your needs and take advantage of health and wellness opportunities identified by the team.

If you have a primary care provider at Carle Champaign on Curtis, Carle Urbana on Windsor, Carle South Clinic Family Medicine, Carle Danville, Carle Monticello or Carle Rantoul, this free service is available to you. Ask your primary care provider if you are eligible. 

The Population Health Team

Population Health team members work with doctors and nurses to take care of our patients.

The core members of your team may vary by location, but could include:

• Care Coordinator – Helps you understand and manage illness.
• Social Worker – Assists with transportation, housing, access to healthy food and family support.
• Pharmacist – Answers questions about your medications and can find solutions if medications cost too much.
• Health Coach – Helps you set and achieve health goals.
• Registered Dietitian – Provides a nutritional assessment, nutritional education and handouts, counseling, and more

Annual Wellness Visits

All patients age 65 and older are eligible for an Annual Wellness Visit as a free benefit of their Medicare or Medicare Advantage plan. During this visit, you’ll meet with a member of your care team to have a focused discussion around your specific health risks and wellness needs. The care team member will review your medical conditions, current medications, immunizations and other preventive care needs, and perform risk-based assessments. After gathering this information, the care team member will review any additional lifestyle changes that you can make in order to stay healthy, active and as independent as possible.

Advance Care Planning

Advance care planning assures your wishes are understood and communicated to healthcare professionals and your loved ones, even when you aren't able to speak for yourself.

For help with advance care planning, Carle offers the Respecting Choices^® program to assist patients in making informed decisions about future healthcare needs.

To get started, call your primary care provider’s office to schedule a phone visit with a social worker or an advance care planning facilitator. You may also visit the Events page to find upcoming virtual advance care planning sessions.

Medical Homes

Healthcare can be complex. Carle Health is committed to providing high-quality, well-coordinated care within your primary care medical home. As a member of a medical home, you can expect to be an active participant in your healthcare. This team works with you so you can get the right care, at the right time.

Your team consists of your primary care provider (PCP), nurse practitioners, physician assistants, registered nurses, medical assistants, service representatives and other support team members. Your PCP is your team leader and ensures all team members are consistently communicating about your medical needs and progress. In a medical home, care is well coordinated and focused on you.

The most important part of this patient centered medical home is you. Your care team is here to support you and your health, focusing on a combination of prevention and treatment actions when necessary. We’ll work with you to make sure we’re always meeting your healthcare needs.

Post-Acute Care

Often, patients have completed their acute hospital treatments and are ready for the transition to the next phase of their recovery – but they may not feel back to their pre-hospital self. Our Care Transition Specialists, together with social workers, will work with you and your family by discussing your concerns and identifying resources available for your discharge plan from the hospital. We’ll help make the transition as easy as possible, centered on your unique needs.