We are an innovative and collaborative department that endeavors to effectively address the increased prevalence of chronic disease, healthcare disparities, and the need for transitions of care support. Our department helps to ensure home health needs, addresses healthcare access issues, provides continuity of care, and patient-specific programs focused on meeting patients where they are and, where appropriate, treating patients beyond the hospital walls.
Programs extend throughout Virginia and include resources for the well-being and care of patients transitioning from the hospital to a partner care facility, home, or home with home health. They also focus on specific patient populations.
The department seeks to address the needs of our unhoused, underserved, and aging populations, patients with complex health and social needs, and members of vulnerable populations in communities that have historically faced barriers to successful healthcare outcomes.
Our continuity of care programs aim to decrease costs while improving health outcomes and patient experiences through data-driven, evidence-based workflows, and program best practices. We provide post-discharge case management, continuity of care support, home health, cutting-edge technology, clinical support and escalation, primary care bridging, resource provisioning, mobile care, community health worker support, pharmacy consultation and medication reconciliation, and a behavioral health program for eligible patients.
Our Commitment to Health Equity
A world-class academic health system with community care throughout Virginia, UVA Health serves a diverse range of communities facing health disparities. Promoting equity for those we serve is central to our mission. In fact, we made cultivating healthy communities and belonging for all one of the three main goals in our 10-year strategic plan.
Key steps we’re taking to promote equity include:
- Asking patients screening questions to learn what disparities they face, so we can connect them with resources to help
- Building community partnerships
- Giving financial help
- Offering more primary care appointments
- Expanding telehealth options to make appointments easier to attend
- Neighborhood health initiatives to give people more access to care where they live
- Population health programming, like Interactive Home Monitoring, the Homeless Consult Service, the Community Paramedicine Program, and the Virginia at Home Program
Workforce Development
We’re also working to reduce disparities with our Earn While You Learn program. Participants earn a competitive salary while training for a needed healthcare role. The program helps people train for in-demand healthcare careers without going into debt.
Inclusion at the Core
Inclusion and equity are foundational to our overall aims to:
- Be the best place to work
- Give value-based care
- Deliver quality and safety that create superior outcomes
We want every patient to have the best care experience.
UVA Health - Population Health Department
Phone: 434.243.6388 | Secure Fax: 434.244.9433
Email: populationhealth@uvahealth.org
Concerns or Complaints