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Referring to Population Health

Many of the times when patients most need to talk to a healthcare professional happen outside of clinics and hospitals. Population Health can help bridge the gap, leading to better outcomes for your patients. Our Population Health team helps patients:

  • Transitioning from care
  • Managing complex conditions
  • Learning about health management
  • With unique concerns related to travel or housing
  • With behavioral concerns

Who Is Eligible for Population Health?

Most of our programs are intended for people 18 years of age and older.

All referrals must be for individuals who reside in Virginia.

All of our programs are intended for a specific group of patients. If you have a patient who you think we could help but need more help determining how to refer, please contact us.

Virginia at Home

Virginia at Home is a home-based primary care program. This program helps older adults with complex medical concerns and needs. VaH brings UVA Health care to homebound patients, improving quality of care and reducing hospitalizations.

To qualify, patients must meet the medicare criteria for being homebound. This means they have trouble leaving home without help because of an illness or injury.

If you are a UVA Health Provider, use Epic to refer. If you are not, you can contact us directly at [email protected].

Medicine HOME

Complex care patients need care that maintains seamlessness of care while also staying rooted in patient goals and needs. By providing team-based care that is data-driven and holistic, our Medicine HOME team is able to provide care that goes beyond for these patients. Some of the conditions we provide care for include:

  • Diabetes
  • Sickle Cell Anemia
  • Chronic Pancreatitis
  • ESRD
  • Congestive Heart Failure
  • COPD
  • Substance Use Disorder
  • Cirrhosis

If you think this sounds like a service your patient would benefit from, please use this form to refer them.

Behavioral Health

We offer evidence-based therapies, education, and help individuals learn skills that help them cope and follow through with treatment. This service is not intended for crisis intervention or for patients who you feel are a danger to themselves or other. You can refer to our program through this form.