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Services in Minnesota

Bluestone’s model of care, tailored to patients living with multiple chronic conditions and disabilities, recognizes that patients need an approach to care that is preventative, proactive and includes all members of the care team. The care team is comprised of Bluestone medical providers, nurses and social workers collaborating with patients’ other healthcare providers and families.

Bluestone uses a mobile clinic approach to provide care to patients where they are, including in residential and home-based settings.  We invest in simple, yet effective, technology that allows the entire care team to communicate 24-7.

This proactive approach to chronic and disability care means scheduled visits, a focus on preventative care services and screenings, and goals of care discussions.

Learn more about our unique model of care. 

In Minnesota, Bluestone Physician Services provides the following services:

Geriatric Primary Care

Care Coordination

Behavioral Health

Integrated Care


Geriatric Primary Care

Bluestone Physician Services has provided primary residential care to elderly patients in Minnesota assisted living and memory home settings since 2006. Physician-led provider teams make regular, on-site visits with the goal of improving health, decreasing the severity of medical issues and reducing emergency and hospital admissions.

Superior care for patients

Under Bluestone’s personalized, on-site care, patients:

  • Experience a model of care created specifically for them.
  • Avoid exposure to germs and illness found at traditional clinics.
  • Benefit from collaboration between provider, nursing staff and family through the Bluestone Bridge, an online communication tool.
  • Experience fewer emergency room visits and hospitalizations.
  • Receive proactive care for chronic conditions, including dementia.
  • Enjoy social interaction from provider team visits.
  • Receive proactive, comprehensive care planning with their family and provider to meet their individual needs.

Peace of mind for families

Family members enjoy more quality time with their loved one while spending less time traveling to appointments and sitting in waiting rooms. With on-site lab, X-ray and other support services, the need to leave home is further reduced. With the Bridge, they also have the ability to communicate directly with their Bluestone provider and the rest of the patient care team.

Provider teams work with all health plans, including Medicare and Medicaid, and Bluestone charges no additional fees to residents or communities for our services.

Added benefits for community staff

Bluestone aims to help community staff through seamless collaboration, which ultimately improves patient care. Staff in Bluestone partner communities experience:

  • Collaboration with health care providers who understand the residential care system
  • Coordination with on-site X-ray and lab services, and home care and hospice companies
  • Seamless communication with Bluestone and families, plus easy prescription ordering, via the Bluestone Bridge
  • Continuity of patient care, including transitional care management, which lowers hospital re-admissions
  • Oversight of medication, refills and medical and prescription forms
  • Ongoing support, education, CEU and training opportunities

Care Coordination Services

Since 2011, Bluestone Physician Services has contracted with Minnesota health plans to provide care coordination services to seniors and people with disabilities. The goal of care coordination is to provide care for the whole person through an integrated approach with community, medical and mental health providers.

Minnesota has three programs that offer care coordination services: Minnesota Senior Health Options (MSHO), Minnesota Senior Care Plus (MSC+) and Special Needs Basic Care (SNBC). Bluestone contracts with Blue Cross Blue Shield of MN, HealthPartners, Medica and UCare for these programs.

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.

Care coordinators are nurses or social workers who are local to the communities they serve.

One SNBC care coordinator is assigned to each member, providing continuity of care. SNBC coordinators:

  • Make face-to-face visits.
  • Arrange services and obtain equipment.
  • Provide information regarding community resources.
  • Assist in making appointments with health care providers.
  • Explain the benefits of the health insurance plan.
  • Provide education on health promotion activities and medications.
  • Manage transitions.

MSHO/MSC+ Care Coordination

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

Care coordination services are provided as part of the care system function. Care coordinators are either nurses or social workers whose role is to provide assistance navigating complex medical systems and overall coordination of health care needs. Care coordinators meet 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, care coordinators work closely with community staff and the Bluestone primary care team. Bluestone is committed to working as part of an interdisciplinary care team to provide all aspects of care, including care plans and rate tools.

One MSHO/MSC+ care coordinator is assigned to each member, providing continuity of care. MSHO/MSC+ coordinators:

  • Make face-to-face visits.
  • Arrange services and obtain equipment.
  • Provide information regarding community resources.
  • Help make appointments with health care providers.
  • Explain the benefits of health insurance plan.
  • Provide education on health promotion activities and medications.
  • Manage transitions.

Medical Home (Health Care Home) Care Coordination

Bluestone Physician Services is certified by the state of Minnesota as a Health Care Home. This certification ensures that Bluestone:

  • Enhances access to and continuity of care
  • Facilitates care team communication via the Bluestone Bridge
  • Identifies and manages patient populations
  • Plans and manages care
  • Tracks and coordinates care
  • Measures performance and makes quality improvements


For questions about care coordination or to locate a care coordinator, call 651-342-4284.

Behavioral Health Program

The Bluestone psychiatric team provides both on-site and virtual visits for patients requiring psychiatric care.

Who needs psychiatric care?

Older adults have special physical, emotional and social needs. Age-related complications include dementia, depression, anxiety and late-life schizophrenia. Other concerns may include difficulty coping with change, stress, death, depression, memory problems, anxiety or agitation. Sometimes chronic medical conditions cause emotional problems to occur for the first time in older adults. Psychiatric care offers valuable help to older adults who are coping with these changes in health and function.

On-site or virtual visits by a psychiatrist allow patients living in a group-home setting or attending community day programs to receive the care they need.

How does psychiatric care through Bluestone work?

A patient residing in a community where Bluestone provides care first sees the Bluestone primary care team to determine if a referral for psychiatric care is needed. In addressing complex situations involving both medical and mental illness, Bluestone primary care providers collaborate closely with the psychiatric team to manage medications and consult on additional interventions to support the patient’s mental health.

When a patient is referred for Bluestone psychiatric care, a visit date is set for either an in-person or virtual visit. The first visit includes getting a complete medical history; a neurological exam that includes memory, problem-solving, language and counting tests; a mental status exam; and an assessment of functional capabilities. It is beneficial to have family or other caregivers present who can help provide information and observations that the patient may not be able to articulate. The psychiatrist then develops a plan to address mental health issues and establishes a follow-up schedule to track progress.

How are virtual visits conducted?

Bluestone uses telehealth visits to give patients real-time access to providers. A Bluestone staff member or other healthcare professional assists with the setup. Bluestone employs video technology that allows the psychiatric team to conduct patient interviews while incorporating the required privacy and security measures. Bluestone patients enjoy their follow-up visits from the comfort of their residence with minimal disruption to their daily routine.

Goals of the psychiatric care team

The primary purpose of psychiatric treatment is to improve the patient’s quality of life. Additional goals include:

  • Educating family and caregivers on the risks and benefits of psychotropic drugs and avoiding or reducing the use of these medications where possible
  • Educating and involving nursing staff at residential communities to support psychiatric care
  • Avoiding hospitalizations for psychiatric issues
  • Reducing the impact of high-cost medications by using generic equivalent prescriptions

Bluestone behavioral health program elements

  • Facility Programming
    • Staff training on behavior plans and memory care program development
  • Consultation
    • Primary care teams and care coordinators consult with Bluestone psychiatrist
    • Routine antipsychotic management
    • Behavioral health-related transitions of care
  • Tele-Health/Virtual Visits
    • Community-based crisis management
    • Ongoing medication management
    • Supported by selected payers
  • Face-to-Face
    • On-site psychiatry visit
    • High collaboration with facility/community staff
    • Supported by all payers
  • Psychiatric Primary Care (Medical Home)
    • Intensive psychiatric management for high-risk medical home patients

Integrated Care Program

Bluestone Physician Services’ roots are in the disability community. The Bluestone model was originally developed to meet the unique and growing needs of people living in group-home and residential care communities. This eventually expanded to assisted living settings. Our integrated care teams include care coordinators and primary care providers serving those with complex chronic conditions who 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. (The Social Security Administration or the state medical review team determines “certified disabled” status).

Through partnerships with community disability providers and Special Needs Basic Care (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 advanced practice practitioners and care coordinators specialize in the unique needs of individuals 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 preventative and chronic care has been shown to reduce the need for emergency room visits and hospitalizations, and significantly improves overall health.

Patient benefits

  • 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

Family benefits

  • Confidence that your family member is well cared for
  • More time for personal activities, as time spent traveling to appointments or in waiting rooms is eliminated
  • Ability to contact the provider with questions or comments

Group-home staff benefits

  • Continuity of care for your clients
  • Collaboration with healthcare providers who understand the unique needs of people with disabilities
  • Ease of communication with healthcare providers and expedited prescriptions and orders via the Bluestone Bridge
  • Ongoing support and education for staff

Community-based primary care for people with disabilities

Bluestone integrated care teams see patients regularly in their own homes and within other patient-chosen settings with the help of programs like Clinic Without Walls (CWOW). Many of our patients identify a primary care provider, but they have limited or no access to him or her. In these cases, we assure the patient’s medical needs are 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 a specialty care referral. Care coordinators offer ongoing support for patient health and wellness.

Some enrollment requirements may apply.

Current partnerships include:

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