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Care Coordination

Bluestone began MSHO and MSC+ Care Coordination in April of 2011 for Bluestone primary care patients. When we started, we were determined to create a care coordination model designed specifically for the needs of our residential care patients and the communities we serve. Bluestone also contracts with several local health plans to provide this service as well as coordination services for people with disabilities throughout the state of Minnesota. The goal of this program is to assist patients in living at the highest level of independence.

What is Care Coordination?

Care Coordination is a service all patients with certain insurance plans receive. Care Coordinators can be employed by counties (case managers), health plans, or care systems. Care systems are often clinics such as Bluestone Physician Services. The role of the Care Coordinator includes a mandated annual assessment, care planning, obtaining equipment and services, completion of the customized living tool and coordination of medical, social and mental health services. Our goal is to raise the quality bar, through collaboration and improved communication to prevent duplication of services.

What can you expect from your Bluestone Care Coordinator?

For Seniors:

  • Each facility (with waiver beds) will have a designated Care Coordinator
  • Facilities will be notified via the portal of new care coordination patients and upcoming assessments
  • The Care Coordinator will work closely with nursing staff to complete an assessment and rate tools accurately
  • Assistance with obtaining equipment and services
  • Resource for insurance or health system questions, including medication coverage
  • Care Coordinators work closely with our primary care teams
  • Transition of care assistance
  • Care Coordinators or our office staff are available for training on waivers, Medicare and Medicaid among other topics

For People with Disabilities:

  • Patients will receive a comprehensive assessment in their home or choice of environment
  • Assistance with general navigation of the health care system
  • Coordination with other members of the care team, such as medical and county staff
  • Unique to Bluestone Care Coordination is direct access to Medical oversight and consultative services.

What is Healthcare Home Care Coordination?

A Healthcare Home (HCH) is an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities. Bluestone Physician Services has been a certified Healthcare Home provider since 2010.

An HCH Care Coordinator is assigned to all patients with a Bluestone Physician. The HCH Care Coordinator can assist the medical team, facility staff, and family with resources such as transportation, durable medical equipment, and managing patient registries for this high-risk population.

The HCH Care Coordinator is available as support for the physician interdisciplinary teamwork and available for special projects such as POLST process and planning, care planning, and problem-solving.

How is a Healthcare Home Care Coordinator different from a Health Plan Care Coordinator?

Care Coordination is an insurance benefit that patients on Medicaid with certain health insurance plans receive. Care Coordinators are either Nurses or Social Workers that are there to assist patients with many of their medical needs. The role of the Care Coordinator is to provide guidance, support, information, education, assistance navigating complex medical systems and overall coordination of patient’s health care continuum.

A Care Coordinator meets with the patient in their home, reviews current physical, social and psychological needs, work with patients to identify goals and assists with securing resources and services that would be of benefit to the patient.