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Bluestone’s Model of Care

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.

Examples of Bluestone Care Sites and Programs

Care Sites

  • Assisted Living and Memory Care Settings
    • Physicians and advanced practice providers provide onsite, primary care visits with a focus on chronic care management and quality of life.
  • Group Homes
    • The Bluestone integrated care team, made up of physicians, advanced practice providers, RNs and social workers have a wealth of disability care experience. They provide on-site care management and primary care with a focus on independence and person-centered care.
  • Private Homes
    • Bluestone’s Clinic Without Walls (CWOW™) program integrates high-touch care management with as-needed medical care to assure optimal primary care and meet the full range of person-centered needs.
    • Bluestone’s care coordination programs provide episodic and longitudinal care management under contract with special needs plans and Medicare Advantage plans.

Programs

  • Patient-Centered Medical Home (PCMH)
    • Primary Care
    • Care Management
  • Care Management
    • Care Coordination
    • Post-Acute Care Management
    • Behavioral Health

A team-based approach

Bluestone’s innovative integrated care model brings together primary care and care coordination offerings into a data-driven interdisciplinary care team.

BLUESTONE INTEGRATED CARE

Customized based on the patient’s needs

TRADITIONAL SYSTEMS OF CARE

One-size-fits-all approach

CONNECTED:

  • Primary care model provided onsite via mobile clinic staff serving those who cannot (or choose not to) visit traditional clinics.
  • Team-based model includes primary care and care management support
  • Highly integrated with community support
DISCONNECTED:

  • Fragmented system where primary care, specialty care and community resources are disconnected.

 

 

 

PROACTIVE: Interventions driven by analytics

  • Value-Based: Coding optimization and cost management ensure sustainability.
  • Risk stratification, comprehensive assessment, gaps in care tracking and data drive care model and patient experience.
REACTIVE: Reactionary interventions resulting in over-serviced, high-cost treatment.

 

 

 

 

 

 

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