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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.

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

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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
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