The Interactive Home Monitoring (IHM) program is a comprehensive care transition service for eligible patients discharged from the UVA Medical Center, including those leaving the emergency department, inpatient units, and ambulatory clinics. The program aims to reduce preventable complications and poor health outcomes that often occur after discharge by providing continuity of care through targeted support. A dedicated team of Population Health Case Managers, Clinicians, and Behavioral Health Therapists works directly with patients to address gaps in care, manage behavioral health needs, support follow-up with a primary care provider, and ensure access to appropriate resources. By increasing patient safety, education, and engagement, the program helps reduce hospital readmissions, non-emergent ED visits, and overall length of stay—ultimately improving outcomes and lowering costs for both patients and the Medical Center.
Eligibility: UVA Health patients who live in Virginia or are staying in the state during treatment, and who have recently received care in the emergency department, in the hospital, or through outpatient services, and are returning home with or without home health care services.
If eligible, the IHM Program will provide:
- Follow-up appointment scheduling assistance
- Home monitoring equipment--if appropriate--and remote vitals monitoring managed by program RNs and APP team are available for patients based on clinical necessity. IHM and APP team care are considered post-discharge hospital services. Insurance is billed for these services, and all patients are informed and consented prior to enrollment.
- Post-discharge medication reconciliation completed by an IHM UVA Health Pharmacist
- Assessment of health-related social needs
- Short-term behavioral health support and/or assistance with finding a long-term counselor
