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For a decade, Population Health has supported patients from pediatrics to geriatrics. That includes the use of innovative technology for chronic disease management, transitional care, and access to primary and specialty care through data-driven workflows and collaboration with clinical and operational leaders across inpatient, ambulatory, emergency, and community settings.

This important arm of UVA Health exists to improve patient access, progression, and health outcomes while also strengthening performance in readmissions, length of stay, capacity, value-based care, and building community trust. 

History  

Population Health began at UVA Health in January 2016 with the launch of Be Well, a pioneering wellness program for team members and their families (now retired). This work laid the foundation for clinical expansion with the launch of Interactive Home Monitoring (IHM) in October 2017 to address high readmission rates — reducing readmission rates by more than 5% in the first six months. IHM has since grown into the department’s largest program, now caring for more than 6,000 patients annually across Virginia.  

The establishment of IHM was followed by a multi-year (2017–20) expansion into hospital-based care, beginning in the inpatient setting before extending into pediatrics, specialty care, emergency department, and ambulatory. From care coordination to chronic disease management, the programs help reduce avoidable utilization, close care gaps, support safe transitions, establish primary care relationships, and improve continuity of care. 

During the peak of COVID in 2020, the team rapidly launched Emergency Department (ED) IHM in collaboration with advanced practice providers (APPs) to prevent avoidable admissions. As the department matured, Population Health made a strategic shift toward long-term sustainability, creating multiple revenue streams that now include nearly $17 million in grant funding, philanthropic support through the UVA Health Foundation, and clinical billing. 

“Population Health is absolutely critical in caring for our patients and community, and our care does not stop when a patient leaves the hospital,” says Mitchell Rosner, MD, MACP, FRCP, CEO, UVA Health, and EVP for Health Affairs, UVA. “It’s gratifying to see the thriving department it has become and to think of how many people have benefited from their services.” 

In its decade-long tenure, Population Health became an early leader within UVA Health in social drivers of health screening. It developed new care models including a primary care clinic to support UVA-Wise students and employees, Community Paramedicine, Virginia at Home, Bridge to Primary Care, Mobile Care Unit, Homeless Consult Services, WellAware, Medicine HOME, Transitions of Care, Behavioral Health Services, and Pediatric Access and Team-based Health (PATH) case management. That cemented Population Health as a driver of coordinated and sustainable care across the communities we serve. 

In June 2024, Population Health expanded to include teams from Continuum Home Health and Post-Acute transitions of care — creating a unified strategic direction for managing care for our patients outside our immediate facilities. As a systemwide partner, Population Health also collaborates with Telehealth, UVA-Wise, UPG, UVA, UVA Health Foundation, and more on initiatives and programs to advance research, patient care, education, and community integration. 

The Team 

Since its beginning, Novella Thompson, MBA, MA, ALM-C, FACHE, has served as the University Medical Center leader for Population Health. Today, she oversees a team of 154 largely remote team members across 14 Population Health programs, with the support of Tracey Hoke, MD, MSc, FAAP, Chief of Quality, Population Health, and Post-Acute Care. 

“The Population Health Department was founded on psychologist Carl Roger’s principle of Unconditional Positive Regard (UPR),” shares Thompson. "The belief that every person deserves acceptance, dignity, and care simply because they are human. As leaders, we carry that principle forward by how we design systems, support our teams, and serve our communities. It continues to shape our culture and guide our work today."

With a commitment to ensuring every patient receives the highest quality care experience, Population Health continues to be a strong difference maker in our mission of transforming health and inspiring hope for all Virginians and beyond.