Why Health Is More Than Healthcare
At Tri-County Health Network (TCHNetwork), we understand that your health is about more than just doctor visits. It’s shaped by where you live, what you eat, how you get around, your mental well-being, and the support systems you have. That’s why we take a Whole-Person-Centered Approach, looking at all areas of your life to help you thrive.
We partner with you to identify barriers to well-being and connect you to the care, resources, and support you need. Whether you’re facing chronic illness, struggling with housing or food access, or simply trying to find your way through a complex system, we’re here to help.
How to make a referral to a Care Coordination program:
Referrals can come from anyone or any organization:
Fax: 720.712.9100
Call: TCHNetwork’s main office at 970.708.7096
Online: TCHNetwork’s referral form
Email: cc-referral@tchnetwork.org
Programs That Support Your Journey:
- ADRC (Aging and Disability Resource Center) Options Counseling
- Behavioral Health Care Coordination
- Durable Medical Equipment Lending Closet
- Frontier Senior Services
- High Fidelity Wraparound
- Medicaid Care Coordination
- Pathways Program
- Palliative Support Services
- Retired and Senior Volunteer (RSVP) Support Program
ADRC (Aging and Disability Resources for Colorado):
- Funded by Region 10
- Eligibility:
- Must live in Ouray, San Miguel or the West End of Montrose County
- Adults over the age of 60: Need information on resources for support and services, or an in-home assessment for funding support through the Region 10 Area Agency on Aging.
- Adults under the age of 60 with any disability or chronic condition: Need information on resources for support and services.
- Caregivers of any age: Caring for an adult over 60 or grandparents over 55, raising a grandchild.
- Offers Options Counseling to older adults and individuals with disabilities to explore long-term care choices. Provides referrals to in-home services, meal programs, transportation, and caregiver support
- Supports clients in navigating Medicare, Medicaid, and other benefit programs
- Promotes aging in place through personalized care planning and local resource coordination
- Connects clients to assistive technology, durable medical equipment, and home modifications
- Helps caregivers access respite services and long-term support
- Collaborates with local agencies to ensure wraparound support
Behavioral Health Care Coordination:
- Funded by the Behavioral Health Solutions Panel
- Eligibility:
- Live or work in San Miguel County
- Mental or Behavioral Health concerns
- Connects individuals to mental health counseling and substance use treatment
- Helps navigate access to Behavioral Health Fund (BHF) and Recovery Access Fund (RAF) for financial assistance
- Provides support for clients dealing with grief, depression, anxiety, and trauma
- Assists in matching clients with culturally and linguistically appropriate providers
- Offers ongoing emotional support, goal setting, and wellness check-ins
- Coordinates care across primary care, behavioral health, and community services
- Helps reduce barriers to care such as transportation, stigma, or insurance limitations
Durable Medical Equipment Lending Closets:
- Available to San Miguel and the West End of Montrose County
- Committed to help individuals remain safe and comfortable in their own home
Frontier Senior Services:
- Funded by the Telluride Foundation
- Supports older adults living in remote and frontier communities
- Connects seniors to in-home care, transportation, and community meals
- Provides assistance with Medicare, benefits enrollment, and legal or housing referrals
- Offers care coordination tailored to individual needs and community limitations
- Conducts home visits and wellness checks to reduce isolation and support independence
- Assists with fall prevention, caregiver education, and chronic condition support
- Advocates for older adults’ rights, dignity, and access to essential services
High Fidelity Wraparound (HFWA):
- Funded by Rocky Mountain Health Plans (RMHP)
- Eligibility
- Youth and families who live or work in Ouray or San Miguel County
- Provides intensive care coordination for youth and families with complex behavioral health needs
- Uses a family-driven, team-based approach to goal setting and problem solving
- Builds a support team of family members, service providers, and community allies
- Prioritizes the youth’s voice and choice in care planning
- Coordinates mental health, educational, and social service resources
- Supports families in crisis with 24/7 access to guidance and advocacy
- Aims to reduce out-of-home placements and keep families safely together
Medicaid Care Coordination:
- Funded through the Regional Accountable Entity (RAE) – Rocky Mountain Health Plans
- Eligibility
- Live in Montrose, Ouray or San Miguel Counties
- Be enrolled in Health First Colorado.
- Supports clients in applying for and renewing Medicaid and CHP+
- Helps newly enrolled individuals understand and use their Medicaid benefits
- Coordinates care with primary care providers, specialists, and social service programs
- Works to reduce health disparities by addressing social drivers of health (e.g., housing, food, transportation)
- Ensures clients receive preventive care, chronic disease management, and follow-up services
- Assists with prior authorizations, referrals, and finding in-network providers
- Advocates for clients who experience barriers or delays in accessing care
Palliative Support Services:
- Funded by San Miguel County
- Eligibility
- Must live in San Miguel County
- Experiencing serious illness, managing chronic conditions, or in need of end-of-life or comfort care
- No age requirement
- Provides non-clinical, compassionate support for individuals with serious or chronic illness
- Focuses on improving quality of life for clients and their families
- Offers assistance with advance care planning and navigating difficult medical decisions
- Coordinates community-based services to support physical, emotional, and spiritual needs
- Helps clients access benefits, home care, and transportation
- Serves as a bridge between clients, caregivers, and providers to align care goals
- Offers grief and caregiver support, even if a client is not on hospice
Pathways Program:
- Funded through the Health Resources and Services Administration (HRSA)
- Eligibility
- Patients with chronic conditions who receive care at participating clinics in
- Receive care at a participating partner – Montrose West End: Basin Clinic, San Miguel County: Uncompahgre Medical Clinic, and Telluride Regional Medical Center. Telluride Whole Health or San Miguel Public Health
- Connects those with chronic conditions to the resources needed to support their health
- 20 Pathways in the Model
- Personalized support
- Improve your health and confidence
Retired and Senior Volunteer (RSVP) Support Program:
- Retired and Senior Volunteer Program (RSVP) Volunteer Site through Region 10
- Opportunities for regular volunteers and senior companions to support older adults in our region
What is Whole-Person-Centered Care?
Our approach focuses on the full picture, your physical, behavioral, mental, and social health. We offer services and support that:
- Address immediate needs while planning for long-term wellness
- Recognize your strengths and build on natural support systems
- Help you navigate complicated systems like Medicaid, mental health, or aging services
- Connect you with care teams that communicate and collaborate
With our Care Coordination team, you’re not alone. We listen to your goals, advocate for you, and collaborate across organizations to ensure your care is personalized and coordinated.
Drivers of Health
Research shows that 80% of a person’s health outcomes are shaped by factors outside the doctor’s office, these are known as the Drivers of Health (also referred to as Social Determinants of Health).
These drivers include:
- Access to healthy food and safe housing
- Ability to pay utility bills or access transportation
- Mental health status and emotional support
- Education level, race, gender, and income
Imagine having to choose between paying rent or affording medication. Or struggling to find fresh food, safe shelter, or a ride to a doctor’s appointment. These choices, and the stress that accompanies them, have a profound impact on health.
That’s why our Care Coordinators, Community Health Workers, Options Counselors, and Enrollment Navigators screen for these drivers, and work one-on-one with community members to:
- Access essential programs like Medicaid, SNAP, or energy assistance
- Navigate housing, transportation, or behavioral health systems
- Set goals and build a realistic plan to improve long-term well-being
