MyMichigan Health established the Continuing Care Clinics in 2023 to serve residents across its 26-county service region who lack timely access to primary care physicians. These clinics are pivotal during critical health transitions, offering responsive care after hospital discharges, emergency department visits, stays in long-term care facilities or while patients await new primary care providers.
Through the Continuing Care Clinics model, MyMichigan Health has demonstrated significant success in reducing poor health outcomes. Patients receiving care exhibit a lower risk of readmission compared to those at other, similar clinics. This achievement is credited to the multidisciplinary team of clinicians who develop personalized care plans, assisting patients in successfully transitioning home while minimizing readmission risks.
Additionally, patients receive referrals for preventive care screenings, further promoting community wellness. The Continuing Care Clinics collaborate with community partners to enhance patients’ access to essential resources including food, transportation and medication. These efforts empower patients to manage their health more effectively and improve recovery.
“Through partnerships with food centers, transportation services and pharmacies, we’ve improved patient access to essential resources like free food, transportation and medication,” said Steve Frazier, MHA, BA, RN, ACN-RN, director of quality and patient safety, MyMichigan Health. “These interventions help patients manage their health, reduce the risk of readmissions and improve overall health outcomes. Additionally, the clinics connect patients without a primary care provider to care, ensuring continuous support and reducing gaps in preventative care.”
For more information and hospital stories, check out the 2025 Community Impact Report. Additionally, this work earned MyMichigan Health a 2025 Ludwig Community Benefit Award. Members with questions may contact Lucy Ciaramitaro at the MHA.