Care Coordination Services

m_HANDS2Bluestone Care Coordination facilitates high levels of patient, family, clinician, and care coordinator partnerships that are needed to support “at-risk” patients. Our results differentiate from other care coordination programs through foundational and scalable attributes that enable teamwork, trusting relationships, and relevant responsiveness.

 

SNBC Care Coordination:

Special Needs Basic Care (SNBC) is a program offered by the State of Minnesota through local health plans for people with disabilities. SNBC takes the place of traditional Medicaid benefits. Health plans contract with clinics and other organizations to provide care coordination.

Bluestone Physician Services is contracted with Medica and UCare throughout Minnesota. Care coordinators are nurses or social workers and live in the communities in which they serve members.

What to Expect From the SNBC Care Coordinator:

  • One care coordinator assigned to each member (continuity of a single care coordinator)
  • Face-to-face visits
  • Arrange services and obtain equipment
  • Provide information regarding community resources
  • Assist in making appointments with health care providers
  • Explain benefits of health insurance plan
  • Provide education on health promotion activities and medications
  • Manage transitions

MSHO/MSC+ Care Coordination:

MSHO (Minnesota Senior Health Options) is a program offered through local health plans that integrates Medicare and Medicaid, including Elderly Waiver Services, health plans contract with clinics, such as Bluestone or Care Systems.

Bluestone Physician Services is a contracted MSHO/MSC+ Care System with Blue Cross Blue Shield of MN (BCBS), UCare and Medica. Care coordination services are provided as part of the care system function.  Care coordinators are either nurses or social workers and work as part of an interdisciplinary team led by a medical director. The role of the care coordinator is to provide assistance navigating complex medical systems and overall coordination of health care needs.

The care coordinator meets with members in their homes to review current health needs, work to identify goals and connect with resources and services. For members residing in assisted living settings the care coordinators work closely with facility/community staff.

Bluestone is committed to working as part of an interdisciplinary care team to provide all aspects of care, including care plans and rate tools.

What to Expect From the MSHO/MSC+ Care Coordinator:

  • One care coordinator assigned to each member (continuity of a single care coordinator)
  • Face-to-face visits
  • Arrange services and obtain equipment
  • Provide information regarding community resources
  • Help make appointments with health care providers
  • Explain benefits of health insurance plan
  • Provide education on health promotion activities and medications
  • Manage transitions

Questions about care coordination or to locate the care coordinator please call 651-342-4284.

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Medical Home (Health Care Home) Care Coordination:

Bluestone Physician Services is certified by the State of MN as a Health Care Home. This certification drives the following:

  • Enhance access and continuity
  • The Bluestone Bridge facilitates care team communication
  • Identify and manage patient populations
  • Plan and manage care
  • Track and coordinate care
  • Performance measurement and quality improvement