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Vision and Voice

Population Health: Better Outcomes, Fewer Emergency Department Visits

Part of our goal to cultivate healthy communities and belonging for all, includes promoting health equity and delivering value-based care. To achieve this, we need to reimagine the healthcare delivery model beyond our hospital walls using data-driven approaches. Our Population Health Department is doing just that to transform the landscape of healthcare delivery.

Recently, at our Medical Center Management Meeting (MCMG), our Population Health Administrator, Novella Thompson, updated us on Population Health’s recent wins. I want to share her key takeaways and highlight how Population Health is playing a vital role in improving health outcomes for our communities while addressing Emergency Department (ED) capacity at the medical center.

Population Health is on the latest frontier of healthcare and is focused on improving chronic health conditions, diseases, morbidity patterns, and how at-risk populations engage with healthcare. Novella stressed the importance of addressing social determinants of health and, in turn, decreasing costs incurred through readmissions, non-emergent ED visits, and accessibility of medications and primary care physician (PCP) care.

Virginia faces unique challenges; over half of our population lives in very low to moderate healthcare opportunity areas impacted by barriers such as geography, an aging population, and low socioeconomic status. Our Population Health Formula emphasizes strategies to address these barriers through intentional relationships with patients, personalized interventions such as helping patients fill their medications post-discharge, and innovative technology to prevent readmissions. 

Health Opportunity Index Graphic
Health Opportunities in Virginia, VDH

In Fiscal Year 2023, the total enrollment of Population Health exceeded 6,000 patients and the department saw great success, including reductions in readmissions, length of stay, and emergency department visits. I am particularly proud of the success of the Community Paramedicine program, an arm of UVA Health’s Population Health Department, which has not only reduced unnecessary ED visits by 23% but has also established valuable relationships with local healthcare providers and received recognition from our community partners for improving the overall emergency response system in Albemarle County.

This recent success is a result of collaborative efforts, partnerships, and community engagement. Together, we are shaping the future of healthcare by caring for more patients while reducing ED visits without compromising our commitment to value-based care. I am optimistic about what we will accomplish with Population Health in the years to come and what it means for our continued success here at the UVA Health University Medical Center.

Your ideas for how we can continue to cultivate healthy communities and belonging for all are invaluable, so please share them with me through the Be Heard Suggestion Box!

Take care and be well,