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UVA Health’s Population Health Department supports patients across the continuum of care — from children to older adults — with services designed to improve health outcomes, reduce unnecessary hospital and emergency use, and make care more accessible. These services are now easier than ever to connect to, now that Population Health Programs are accessible through a single order in Epic. 

Population Health provides case management, continuity of care support, home health, cutting edge technology, clinical support and escalation, primary care bridging, primary care in the home, mobile care, community health worker support, community paramedicine, pharmacy consultation and medication reconciliation, and a behavioral health program for eligible patients: 

• Children and adults referred from any UVA Health setting — inpatient, outpatient, Emergency Department, or direct referral.

• Patients (or their caregivers) recently discharged from UVA Health and referred to a patient program. 

• UVA employees (health system and academic including University Physicians Group and UVA-Wise) such as fellows, medical residents, staff, faculty, clinicians, and clinical team members. 

• Eligible individuals must reside in the Commonwealth of Virginia at the time of service. 

Through Population Health, UVA Health provides valuable services to patients such as chronic disease management, removal of barriers to healthcare, patient access to primary and specialty care, and care delivery beyond University Medical Center. 

Historically — to direct patients to these services — care providers would need to know specific program details and related criteria.  Effective Tuesday, July 8, all Population Health programs are being integrated in Epic, allowing providers and team members to submit a request for review easily — based on patient care needs and specific barriers to ideal health outcomes. Examples include: 

• Transition Support: decrease length of stay (LOS) with remote patient monitoring and care coordination. 

• Behavioral Health: anxiety/depression, substance use, crisis intervention. 

• Social Drivers of Health (SDOH): housing support, home safety, food insecurity, and/or barriers related to language/literacy, finances, or transportation. 

• Ambulatory Support: teams to support access barriers, lack of established primary care physician, utilizing Population Health programs in place of the Emergency Department (e.g., IV fluids in the home, hospital bed delivery and support, falls risk assessment, need for care on the street, and mobile primary care). 

Reporting any of these criteria into Epic seamlessly will result in timely follow-up from Population Health, which will assess the patient’s needs and eligibility to pair them with the right services. All programs can be accessed by using the Epic Order–Population Health Program Intake. To get started, please review the Tip Sheet.

“Thank you for your support in connecting patients to programs and services designed to lead to beyond-hospital, clinic, and Emergency Department care — ultimately resulting in healthier outcomes within the communities we serve, and for supplementing University Medical Center teams that provide clinical care,” says Novella W. Thompson, MBA, MA, ALM-C, FACHE, Administrator, Population Health Department, UVA Health. 

Questions about Population Health programs? Visit the website, call 434-243-6388, or email populationhealth@uvahealth.org.