The Department of Population Health serves as a system-wide infrastructure embedded across UVA Health, supporting patients, care teams, and communities throughout the Commonwealth. Through an integrated portfolio of clinical, operational, and strategic services, we advance high-quality, value-based care across the full continuum.
Organized across six core divisions—Access & Care Navigation; Post-Acute & Transitions of Care; Population Health and Value-Based Care; Serious Illness & Longitudinal Care Planning; Connected Care; and Post-Acute Behavioral Health—the department aligns programs, resources, and expertise to improve access, strengthen care coordination, and support patients with complex and evolving needs.
Our work extends beyond traditional care settings, connecting emergency, ambulatory, inpatient, and post-acute services to reduce avoidable utilization, support safe and timely transitions, and improve continuity of care. We serve as a critical connector across UVA Health, enabling more efficient resource use while enhancing patient outcomes and experience.
We are committed to ensuring every patient receives high-quality, patient-centered care—grounded in safety, clinical excellence, and partnership—as we work to achieve meaningful and sustainable health outcomes.
Our Services and Capabilities
- Complex care management and transitional care services
- Care navigation and access support across primary, specialty, and community-based services
- Remote patient monitoring and connected care technologies for real-time clinical insight
- Mobile care delivery, including in-home geriatric primary care and community paramedicine
- Pharmacy consultation and medication reconciliation
- Behavioral health services, including post-acute and community-based support
- Community health worker integration and clinical escalation pathways
- Serious illness care and longitudinal care planning
- Comprehensive home health services, including skilled nursing, therapy, and care coordination
Our Approach
Our approach is grounded in data-driven workflows, evidence-based practices, and strong collaboration with clinical, operational, and community partners. We align closely with providers and health system leaders to ensure coordinated, efficient, and patient-centered care delivery.
Population Health plays a critical role in advancing UVA Health’s system-wide priorities, including patient progression, readmission reduction, length-of-stay optimization, behavioral health utilization, and sustainable growth. Through this work, we strengthen performance across the continuum while supporting the long-term health of the communities we serve.
UVA Health: Delivering Excellence Across Virginia
UVA Health is an integrated academic health system that delivers high-acuity, high-quality care throughout the Commonwealth. Our system includes a nationally ranked academic medical center with a Level I trauma center, a Level IV NICU, Virginia’s first NCI-designated Comprehensive Cancer Center, and UVA Health Children’s—the top-ranked pediatric hospital in the state.
The health system also comprises three community hospitals, a specialty rehabilitation hospital, and an extensive network of primary and specialty care clinics that serve both urban and rural communities.
Our Guiding Principles
- Center our work around the needs of patients
- Support and empower one another as a unified team
- Pursue excellence across clinical care, research, and education
- Make transparent, data-informed decisions aligned with our long-term goals
- Deliver the highest quality care with a focus on safety and an exceptional patient care experience
- Embrace innovation and continuous learning
- Steward our financial, environmental, and organizational resources responsibly
- Define clear objectives, measure progress, and celebrate success
- Strengthen UVA Health’s presence and trust across the communities we serve
UVA Health - Population Health Department
Phone: 434.243.6388 | Secure Fax: 434.244.9433
Email: populationhealth@uvahealth.org
Concerns or Complaints