MyMichigan Awarded for Continuing Care Clinics, Reduction in Poor Health Outcomes
MyMichigan Health has been awarded the prestigious 2025 Ludwig Community Benefit Award by the Michigan Health and Hospital Association (MHA) for its Continuing Care Clinics. MyMichigan was one of three organizations to receive this honor. The award, named in memory of Patrick E. Ludwig, a former MHA president renowned for his dedication to investing in community health, acknowledges member organizations that are integrally involved in collaborative programs aimed at improving the health and well-being of Michigan residents.
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 timely 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, we have demonstrated significant success in reducing poor health outcomes. In fact, patients receiving care through the Continuing Care Clinics exhibit a lower risk of readmission compared to those at other similar clinics,” said Steve Frazier, B.A., R.N., A.C.N.-R.N., director of quality and patient safety post-acute, MyMichigan Health. “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 screenings, further promoting community wellness.”
The Continuing Care Clinics actively collaborate with community partners to enhance patients’ access to essential resources, such as food, transportation, and medication delivery. These efforts empower patients to manage their health more effectively and improve their recovery journey.
“By partnering with local organizations like The Bridge Food Center of Midland, county transportation services, and pharmacies, we have been able to improve the patients’ ability to access essential resources, such as free food, transportation, and medication support,” said Frazier. “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 care.”
Frazier continued, “By offering free services and connecting patients to necessary care, our Continuing Care Clinics program ensures that all community members, regardless of financial situation, receive the care they deserve. To have received an award for this work is an honor for MyMichigan Health and it echoes the legacy of Mr. Ludwig's vision for community health investment.”
