Patient-focused Services

CHI Health Partners has a team of health care professionals that serve as an extension of a patient’s primary care provider. This model of care is called a medical neighborhood, or patient-centered medical home.

How it works:

  • Primary care clinics are outfitted with resources to facilitate better patient care management outside the walls of the clinic. For example, a diabetic patient might only see his or her primary care provider three times a year, but may have ongoing issues or questions that need to be addressed before their next appointment. 
  • A population health coach (also called a care coordinator) and a discharge transition nurse are the touch points for these “high-risk” patients. They follow-up with patients after an office or hospital visit to ensure they understand their care plan and have the resources to follow through. The population health coach is an expert in system and/or community resources and services that can benefit the patient.
  • Health coaches and discharge transition nurses can involve other medical neighborhood providers when there is a need, such as a pharmacist, social worker, or dietician. (Not available in all CHI Health Partners chapters.)


  • Medical neighborhoods provide patient engagement and education, which is vital to helping patients help themselves.
  • Improve patient care and outcomes, and help patients avoid expensive ER visits and hospitalizations—which is where real health care savings will occur.

Learn More:

  • To read more about each part of the medical neighborhood, click on the links on the left side of this page.
  • See testimonials of patients that have benefitted from CHI Health Partners services.