The Interactive Home Monitoring (IHM) program is a comprehensive transition of care program for eligible patients discharged from UVA Medical Center. IHM provides continuity of care post-discharge by providing a dedicated team of Population Health Case Managers, Clinicians, and Behavioral Health Therapists who support and collaborate with patients to match them to resources to address any gaps in their continuum of care, manage the PHQ, address behavioral health needs, and establish care with a PCP--all to increase patient safety, engagement and education, decrease length of stay, readmission and non-emergent ED visits, and improve cost savings for patients and the Medical Center.
Eligibility: UVA Health patients who are residents of Virginia and have recently been discharged from the Medical Center to home or home with home health.
If eligible, the IHM Program will provide:
- Follow-up appointment scheduling assistance (must be listed on the patient's discharge instructions)
- Transportation coordination to follow-up appointments associated with the hospital stay and discharge instructions (legally, an eligible patient is one that lives within a 75-mile radius of the Medical Center, and transportation is provided to appointments listed on the patient's discharge instructions)
- Home monitoring equipment and iPad, if appropriate, and vitals monitoring performed by program RNs and APP team*
- Post-discharge medication reconciliation completed by an IHM UVA Health Pharmacist
- Assessment of Social Drivers of Health
- Short-term behavioral health support and/or assistance with finding a long-term counselor
