Care Coordination

Tri-County Health Network Advocates for Health Equity for Everyone In Our community.

The Connector

TCHNetwork started providing community-based, non-medical Care Coordination services in 2015 when we became the Aging & Disability Resource Center for San Miguel County and the West End of Montrose County. Based on our success as the ADRC, we launched our Palliative Support Services project in 2016. Later, in 2018, Rocky Mountain Health Plans (RMHP) chose TCHNetwork as its partner to provide care coordination to over 13,000 Medicaid members throughout Montrose, Ouray, and San Miguel counties.

Our role in community care coordination is to connect community members to resources that can improve the health and well-being of those members and help them live in our communities for as long as possible.

How do we accomplish this? By providing support, addressing any potential gaps or barriers to quality health services, and connecting individuals and families to all available resources. While we are not clinicians, we do advocate and give a voice to community members who may not have way to do so for themselves. We have Care Coordinators on our team who help our Medicaid members, and Options Counselors available to provide in-home support to people over age 60 or people over age 18 with a disability.

Community Care Coordinators and ADRC Options Counselors help clients in broad ways ranging from providing support in making doctor appointments, arranging transportation, to navigating resources for insecurities in food, utilities, transportation, housing, personal safety, and isolation. We can meet with clients over the phone, in different community locations, or go to a client’s home to offer services.

Clients are referred to us by:

  • Doctors’ offices
  • Hospitals
  • Medicaid
  • Partner agencies
  • Family, friends, and neighbors who think someone close to them could benefit from services
  • Client self-referral

Looking Towards the Future

Due to our success in offering Care Coordination, TCHNetwork is poised to expand our Care Coordination services to more community members who need assistance accessing resources outside of clinics. In late 2020, we will begin offering Care Coordination in select communities for people who are not enrolled in Medicaid. Stay tuned for more information!

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