Interactive Home Monitoring Program (IHM)

The Interactive Home Monitoring (IHM) program is a comprehensive transition program for eligible patients discharged from UVA Health. IHM provides continuity of care post-discharge by providing a dedicated team of IHM Advocates, Clinicians, and Behavioral Health Therapists who support and collaborate with patients to match them to resources to remove barriers to care, manage the PHQ, address behavioral health needs, and establish care with a PCP--all in an effort to impact bed days, increase accessibility, and decrease readmission and non-emergent ED visits. Health System LIPs can make a direct referral through email: CL Discharge Advocates

Eligibility: UVA Health System Patients who are residents of VA & discharged home or home with home health.

If eligible, the IHM Program will provide:

  • Follow-up appointment scheduling assistance (must be listed on the DTP and/or 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 hospital and transportation is provided to appointments listed on the DTP and/or 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 Determinate of Health Needs
  • Up to 8 free sessions with an IHM behavioral health therapist, or a 12-session evidence-based trauma program, if appropriate

To Providers: The IHM program is provided throughout UVA Health System within the state of Virginia. IHM, often known as, Remote Patient Monitoring, provides monitoring of vital signs and other metrics using a platform specifically designed for UVA Health, Population Health by our partners, Locus Health.

The platform allows many departments in the Health System to maintain close watch over every patient, meet patients where they are and assist remotely to establish PCP and follow-up care, reduce travel into Charlottesville for clinic appointments, avoid non-emergent ED visits and admissions, and reduce inpatient length of stay opportunities.

IHM programs are being added to more UVA Health departments daily with the benefit of serving patients in a way that provides exceptional, convenient, hands-on, and interactive, engaged patient care—at home.

Do you want to make a referral to IHM for your patient?
LIPs may make a direct referrals through their Health System email:
CL Discharge Advocates

Still Have Questions? Contact:
Novella Thompson, Administrator:
Jared McComb, Patient Advocacy Manager:
*Interactive Home Monitoring and Nurse Practitioner care are post-discharge hospital services; insurance is billed for these services. All patients are made aware of billing and are consented before enrollment.