1. Bluestone Physician Services Contracted with 150 Assisted Living facilities and Group Homes throughout the metro area, providing on site residential care. 16 providers 3500 patients Unique population Setting of care-residential Frail, high risk Responsible parties Launched healthcare consulting division in 2012 Certified as HCH in July of 2010, recertified in 2011 and 2012.

2. Health Care Home in a Geriatric Setting Unique Challenges –Care Givers as “patient” –Complex, multiple needs –Patient Identification-all are “high risk” “life geography” as predictive model –Coordination with “external” case management/care coordination/homecare

3. Geriatric HCH-Advancements State Progress –MAPCP Toolkit and Resources –Background and description May 1 st Learning Collaborative –Quality Progress MNCM –Care Coordination measures »Advance Care Planning »Follow up after Hospital Discharge

4. PROGRESS Bluestone Progress –Culture Change What we are instead of something we do Integration with primary care and existing care coordination programs –Billing MAPCP Demo State

5. Bluestone Progress –Organization Processes Technology –Quality Advisory Board MNCM Data and reporting

6. HCH Benefits Access and Communication –Communication Portal-”The Bridge” Allows multi directional communication between primary care, care coordination, family, facility staff and homecare/hospice. Care plan and tiering forms incorporated.

7. Benefits of HCH Standards Registries and patient empanelment –Specialty referrals –POLST –Depression screening –Disease management measures/Prevention A1C LDL Colonoscopy –Updating tier form/care plan

8. Benefits of HCH Standards Care Coordination –All Bluestone patients receive care coordination services. –Funding allowed hiring of on site RNs. –Referral Coordination added. –Key player in physician-facility-family relationship.

9. Benefits of HCH Standards Care Plan –Electronic part of communication Bridge –Improvements in patient directed care Care conferences Patient centered goals Family engagement

10. Benefits of HCH Standards Continuous Improvement –Increased emphasis on data Facilities metrics –Patient Experience Survey Bluestone specific –Quality Projects POLST Transitions Facility engagement

11. Thank You Sarah Keenan, RN BSN Vice President Bluestone Physician Services Bluestone Solutions Sarah.Keenan@Bluestonemd.com 651-342-4273