UVA Health, Population Health recognizes the rising need to effectively address an increase in the prevalence of chronic disease, health care disparities, and health access issues. The department provides continuity of care and patient-specific programs aimed at meeting patients where they are, and where appropriate, treating patients beyond the hospital walls. Programs extend throughout the state of Virginia and include resources to provide for the well-being and care of patients transitioning out of the hospital to home and specific patient populations.

This department also addresses the needs of homeless 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.

The goal of the continuity of care programs is to decrease costs, while improving health outcomes and patient experiences, with data-driven evidence-based workflows and program standardization to provide post-discharge case management, cutting-edge technology, clinical support and escalation, a dedicated pharmacy team, and a behavioral health program for eligible patients.

UVA Health, through the Population Health Department, is also rising to meet the needs and recognize the potential of advances in multidisciplinary approaches to healthcare redesign and value-based payment models that support opportunities for our health care providers to give increased attention to population health. 


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
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