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Bluestone Physician Services

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  1. Bluestone Physician Services Contracted with 150 Assisted Living facilities and Group Homes throughout the metro area, providing on site residential care. 16 providers 3500 patients Unique population Setting of care-residential Frail, high risk Responsible parties Launched healthcare consulting division in 2012 Certified as HCH in July of 2010, recertified in 2011 and 2012.

  2. Health Care Home in a Geriatric Setting • Unique Challenges • Care Givers as “patient” • Complex, multiple needs • Patient Identification-all are “high risk” • “life geography” as predictive model • Coordination with “external” case management/care coordination/homecare

  3. Geriatric HCH-Advancements • State Progress • MAPCP • Toolkit and Resources • Background and description • May 1st Learning Collaborative • Quality Progress • MNCM • Care Coordination measures • Advance Care Planning • Follow up after Hospital Discharge

  4. PROGRESS • Bluestone Progress • Culture Change • What we are instead of something we do • Integration with primary care and existing care coordination programs • Billing • MAPCP Demo • State

  5. Bluestone Progress • Organization • Processes • Technology • Quality • Advisory Board • MNCM • Data and reporting

  6. HCH Benefits • Access and Communication • Communication Portal-”The Bridge” • Allows multi directional communication between primary care, care coordination, family, facility staff and homecare/hospice. • Care plan and tiering forms incorporated.

  7. Benefits of HCH Standards • Registries and patient empanelment • Specialty referrals • POLST • Depression screening • Disease management measures/Prevention • A1C • LDL • Colonoscopy • Updating tier form/care plan

  8. Benefits of HCH Standards • Care Coordination • All Bluestone patients receive care coordination services. • Funding allowed hiring of on site RNs. • Referral Coordination added. • Key player in physician-facility-family relationship.

  9. Benefits of HCH Standards • Care Plan • Electronic part of communication Bridge • Improvements in patient directed care • Care conferences • Patient centered goals • Family engagement

  10. Benefits of HCH Standards • Continuous Improvement • Increased emphasis on data • Facilities metrics • Patient Experience Survey • Bluestone specific • Quality Projects • POLST • Transitions • Facility engagement

  11. Thank You Sarah Keenan, RN BSN Vice President Bluestone Physician Services Bluestone Solutions Sarah.Keenan@Bluestonemd.com 651-342-4273