Patient Centered Medical Home

What is a Patient-Centered Medical Home?

A Patient-Centered Medical Home, often called PCMH, is a way of providing primary care that focuses on the whole person. Instead of only treating you when you are sick, your care team works with you to prevent illness, manage ongoing conditions, coordinate care, and support your health goals.

At EJFHC, this means:

• You have a care team that works together.
• Your health history, medications, screenings, and care needs are reviewed regularly.
• We help coordinate referrals, tests, medications, and follow-up care.
• We connect you with community resources when you need extra support.
• We ask for your feedback so we can continue improving care.

Meet Your Care Team

Your care team may include your primary care provider, medical assistant, registered nurse, behavioral health specialist, clinical pharmacist, referral team, care manager, patient navigator, pharmacy team, and other support staff.

Each member of your team has a role in helping you get the right care at the right time. Your team may help with preventive screenings, medication questions, chronic condition support, referrals, follow-up after hospital visits, behavioral health needs, and connecting you to helpful resources.

You are part of the team, too.

We encourage you to ask questions, share your goals, tell us about barriers, and let us know what matters most to you.

Meet Our Providers

Access to Care

We work to make care available when you need it. Established patients may have access to same-day care, routine appointments, follow-up visits, after-hours clinical advice, and electronic communication through the patient portal.

After-Hours Care

When our offices are closed, established patients may call our after-hours nurse line at 616-391-9932 for medical concerns. A registered nurse will help with your questions and contact the provider on call if needed.

Communication With Your Care Team

Good communication helps us care for you safely and effectively. You can help your care team by keeping your contact information updated, bringing your medications to visits, sharing changes in your health, and using the patient portal for non-urgent requests.

Behavioral Health and Primary Care Working Together

Mental health is part of your overall health. Our integrated behavioral health team works with primary care to support patients with concerns such as stress, anxiety, depression, substance use, grief, life changes, and other emotional or behavioral health needs.

Your provider may recommend a behavioral health visit as part of your care plan.

Learn about our Integrated Behavioral Health

Help With Medications

Medications can be confusing, especially when you see multiple providers or take several prescriptions. Your care team and pharmacy team can help review your medications, answer questions, explain new prescriptions, and look for barriers that may make it hard to take medication as directed.

Learn about our Pharmacy Services