High Utilizers of Virginia (HUV)

Project Summary

Project Overview

The Virginia Department of Behavioral Health and Development Services (DBHDS) has contracted with Community Based Care Coordination (CBCS) to launch the High Utilizers of Virginia (HUV) program. The HUV program launched Dec 1, 2021 in Northern Virginia.

The program emphasizes:

In-person engagement with individuals at time of program enrollment

24/7/365 program access for enrollees, including crisis availability

Close coordination with the Collective Medical tools

Engagement and coordination with local resources

Close follow up with enrollees after every provider encounter

Care Plans customized to each enrollee and shared in real-time

HUV Program Goals Include:

o Improved enrollee care.
o Decreased duplication of care efforts across the healthcare community.
o Reduction in mental health admissions amongst enrollees.
o Reduction in general hospital admissions amongst enrollees.
o Reduction in ED visits amongst enrollees.
o Reductions in cost of care amongst enrollees.

HUV program staff work closely will all existing resources that connect with our common patients. HUV staff do not perform clinical duties, nor do we intend to replace any existing resources. Our goal is to serve as a glue that helps fill in the gaps of care that currently exist for patients, and to help make existing resources more effective in their efforts.

Our 24/7 Hotline.

Call (703) 997-7620

Contact The HUV Team


Program Manager
Asia is a Licensed Clinical Social Worker with a background in case management and quality improvement. Working for the Ryan White HIV/AIDS Program, Asia assisted numerous community members whose mental health had faltered because of stigma around mental illness and inequitable healthcare access. Looking to increase healthcare equity and community-based resource collaboration, Asia accepted the position as Program Manager for the High Utilizers of Virginia (HUV) Pilot in Northern VA. Asia leads a team of exemplary Community Health Workers, dedicated to providing clients with the guidance, support, and resources needed to help them remain stable and flourish in their communities.


Community Health Worker
Jessica achieved her B.S. in Public Health. She was inspired to pursue her degree after being an EMT for over 10 years and helping the same people with crises multiple times a month. Her passion is educating community members and promoting equitable service access. As a Community Health Worker with CBCS, she is able to bring the best of her strengths to clients in Northern VA.


Community Health Worker
Kimberly works as a Community Health Worker for the High Utilizers of Virginia Pilot Program under CBC Solutions. Prior to joining CBC Solutions, Kimberly’s work primarily focused on COVID-19 control and prevention. She managed the implementation and execution of COVID-19 staff testing sites within Johns Hopkins Medicine hospitals in the Washington metropolitan area, and assisted in the vaccination of her community by administratively supporting vaccine clinics in Fairfax, VA. She holds a B.S. with honors in Community Health from George Mason University. As a student, she was the programs director of the Student Health Advisory Board—an organization comprised of 26 students who served as liaisons between the student body and the student wellness offices on campus. Her passion for health and the wellbeing of other people is what drives her career in public health. She plans to pursue a Master of Public Health with a concentration in epidemiology to continue prolonging life through disease surveillance, investigation, and evaluation. For fun, she enjoys spending time with her family, playing with her cat Jax, exploring new places, and camping.


Community Health Worker
Tim earned his BS and Master’s degree in Public Health. He boasts a long history of patient care in the region, working for large hospital complexes and smaller, community-based organizations. Tim is a native of Northern Virginia and proud to be supporting his fellow NoVA residents as a Community Health Worker.


Alexis earned her B.S. with honors in Health Sciences. Before joining CBC Solutions, she worked as a Community Health intern researching COVID-19 disparities to successfully improve access to and promote vaccinations within the region. She places high value in getting to know people and believes this to be a crucial step in making a difference. She has interests in communication studies theories and health behavior change and plans to get a master’s degree in Public Health. For fun, she takes pleasure in spending quality time with her friends and family along with watching Netflix’s latest tv series.


Jenn joined CBCS’s HUV Team as a Community Health Worker in June of 2022. She is assigned to the Region One Expansion Team. Jenn is passionate community advocate for girls and women, transition-aged youth, and the LGBTQ+ community. She also champions the open acceptance and de-stigmatization of mental illnesses and substance use disorders. Her most recent work experiences include working as a Case Manager, Acudetox Specialist, and Peer Recovery Specialist at Bridging the Gaps, Inc.; Administrator of the Period Access Distribution Center Administrator in Lynchburg, VA; and for Chestnut Health Systems as Grant Project Assistant/Evaluator for both the Bedford County Family Treatment Drug Court Program and the CABHI Program in partnership with Horizon Behavioral Health. In addition, she is pursuing her M.Ed. in Clinical Mental Health Counseling at the University of Lynchburg. Jenn recently celebrated 11 years of continuous recovery from her own mental health and substance use disorders. In her free time, she draws on her past lived experiences to volunteer in the community as a peer recovery specialist and enjoys exploring and photographing Skyline Drive and the Blue Ridge Parkway.

For more information on the HUV program, please contact:

Suzanne Mayo – Director, Office of Community Integration DBHDS

Enrique Enguidanos – CEO, CBCS