Interactive Home Monitoring Program (IHM)

The Interactive Home Monitoring (IHM) program is a comprehensive transition 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 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. UVA Health LIPs can make a direct referral through email: CL Discharge Advocates

Eligibility: UVA Health patients who are residents of Virginia and have recently 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 Determinants of Health
  • 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 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 UVA Health to maintain close watch over every patient, meet patients where they are, and assist remotely to establish PCP and follow-up care, reduce travel to Charlottesville for clinic appointments, avoid non-emergent ED visits and admissions, and reduce inpatient length of stay.

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 can make a direct referrals through their UVA Health email:
CL Discharge Advocates

Concerns or Complaints

Still Have Questions? Contact:
Novella Thompson, Administrator:
Jared McComb, 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.