Integrated Care Program

Bluestone Physician Services’ roots are in the disability community. The Bluestone  model was developed to meet the unique and growing needs of people living in group home and residential care communities, and eventually expanded to assisted living settings.  The Integrated Care Program is the work of our integrated care teams which are made up of care coordinators and primary care providers who serve those who have complex chronic conditions, but may not live in a residential care community.

Most of the patients served through the Integrated Care Program are “Certified Disabled” by the State of Minnesota, and have insurance coverage through Medical Assistance.  A person is determined “Certified Disabled” by the Social Security Administration or the State Medical Review Team.

Through partnerships with community disability providers and SNBC managed care plans, Bluestone continues to raise the bar on the integration of community, medical, and behavioral health services.

On-Site Primary Care for People with Disabilities

Bluestone’s Integrated Care Team of advance practice practitioners and care coordinators specialize in the unique needs of people with disabilities, working closely with group home staff on all aspects of the patient’s needs.

The Bluestone team visits patients on a regular basis in their homes. This type of preventative and chronic care has been shown to reduce the need for emergency room visits and hospitalizations, and significantly improves overall health.

Benefits for the Patient:

  • High-quality, individualized health care in a safe, familiar environment
  • Primary care oversight of all medical issues
  • Continuity of care with a personal medical team

Benefits for the Family:

  • Confidence that your family member is being well cared for
  • More time for personal activities, eliminating time spent traveling to appointments or in waiting rooms
  • Ability to communicate with the physician when you have questions or comments

Benefits for the Group Home Staff:

  • Continuity of care for your clients
  • Collaboration with health care providers who understand the unique needs of people with disabilities
  • Bluestone Bridge™ (web-based communication tool) for ease in communicating with healthcare providers and updating prescriptions and/or orders in a timely fashion
  • Ongoing support and education for staff

Community-Based Primary Care for People with Disabilities

Using programs such as Clinic Without Walls (CWOW), Bluestone Integrated Care Teams see patients regularly in their own homes and within other settings of patient’s choosing.  Many of our patients identify as having a primary care provider and are unable to access him/her for various reasons.  In those cases, we assure the patient’s medical needs are being met, but do not take over primary care services.   Bluestone Integrated Care Teams treat patients on-site and provide education on health conditions. Bluestone coordinates with the patient’s current primary care providers and the traditional clinic for other care services as needed, similar to the way a referral is given for specialty care services. Care Coordinators offer ongoing support for patient health and wellness.

 

Some Enrollment Requirements May Apply

Current Partnerships Include:

  • ACR Residential Care Homes
  • Scenic Hills Assisted Living
  • Living Well Disability Services
  • Lutheran Social Service of Minnesota
  • Hammer Residences, Inc.
  • Mount Olivet Rolling Acres
  • Opportunity Partners
  • The Phoenix Residence, Inc
  • Mary T Inc
  • Dungarvin Inc
  • Amy Johnson Residence
  • Rising Cedar Assisted Living
  • Gillette Lifetime Specialty Healthcare
  • HealthStar Home
  • Key Medical
  • Medica AccessAbility
  • UCare Connect