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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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