By Martha Jarrett
Bluestone serves an aging population, most with multiple chronic conditions that make their care complex. The average Bluestone patient is 82, has more than eight chronic conditions and resides in a memory care, assisted living, independent living or group home setting. In short, Bluestone serves either the seriously ill and/or disabled populations. In order to better serve our patients and caregivers, Bluestone has created a Care Management Department that houses Post-Acute and Behavioral Health Care Managers.
The primary purpose of these roles is to ensure our patients receive an optimal level of care by joining an already established primary care team. With effective Care Management, our practice can improve patient outcomes, reduce distress, prevent admissions or readmissions, and improve the coordination of care for more complex patients. Care Management contributes significantly to Bluestone’s ability to reduce total costs of care.
Care Management is a promising team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. It also encompasses those Care Management activities needed to help manage chronic illness.
Post-Acute Care Managers
Post-Acute Care Managers assist patients, communities and provider teams who need more support in dealing with all aspects of transitional care. The Post-Acute Care Manager enhances our patients’ care by working closely with hospitals, post-acute settings, primary care providers, families and assisted living communities.
Patient support activities can include the communication of: end-of-life wishes, baseline cognitive and Activities of Daily Living status, accurate medical information to acute/post-acute care settings and assisting with discharge planning. Post-Acute Care Managers ensure the patient is in the most appropriate care setting, for the minimal necessary amount of time.
Behavioral Health Care Managers
Access to mental and behavioral health care services for the disabled and elderly is a growing challenge for many communities. To address the growing demand for mental health services, Medicare has created a new benefit called Behavioral Health Integration. To support this new benefit, Bluestone added Behavioral Health Care Managers (BHCM) to the team.
BHCMs assist patients and communities who need more support for a wide range of mental and behavioral health symptoms and illnesses. BHCMs provide supportive relationships with motivational interviewing and one-on-one coaching, as well as provide alternative health solutions to help increase positive outcomes. As part of the Bluestone primary team, BHCM’s consult weekly with psych providers, which enhances community staff communication and supports personalized care plans. BHCMs support facility staff by providing one-on-one staff and community education, and serve as a primary resource for caregiving skills and creative interventions. BHCMs assess personal and community spaces to ensure they’re safe and supportive; and make recommendations to adjust sensory stimulation and increase orientation, as well as collaborate with activity coordinators and staff to find ways to engage patients in activities. Engaging facility staff to help find non-pharmacological interventions and person-centered approaches to symptom management has been one of the most helpful activities of the program.