Keeping Older Adults Living Comfortably at Home: Stories of Support from TCHNetwork

Keeping Older Adults Living Comfortably at Home: Stories of Support from TCHNetwork

By Ruthie Boyd, Marketing Coordinator VISTA

Doug and the In-Home Assessment Process 

When Tri-County Health Network received a call in 2019 from Donna, RN, about an older gentleman, Doug, who was experiencing some forgetfulness and isolation, the Palliative team jumped to action and conducted an in-home assessment.  

For people like Doug, TCHNetwork conducts an in-home assessment to better understand the situation and the types of care that are needed. An individual, provider or family member may request an in-home assessment for services like housekeeping, personal care (bathing and dressing assistance), home-delivered meals, caregiver support like respite, home repairs, or durable medical equipment. The client is informed about their choices are for services, who the home care agencies are to pick from, who provides transportation, how to sign up for home-delivered meals, and more. If the client needs additional services, they are referred to Region 10 for assistance funding the homemaker and personal care services.   

At the time of Doug’s initial assessment in 2019, he still had a housekeeping service and was able to drive a car and at the assessment he was not open to any help or assistance, but as time wore on and his 6 month check-in came around, Care Coordinator Manager, Amy, did a reassessment and found that Doug could use some additional assistance. He agreed to get help from one of the Palliative support volunteers, who calls him frequently to check in, and Nurse Donna has helped him get down to the senior lunch in Telluride.  

Over the past year, Doug’s health has declined, and the Palliative team has stepped in to help further. Alongside TCHNetwork, the Telluride Medical Center and Nurse Donna have been brainstorming ways to help Doug. From this collaboration came a plan of action. Now, his senior lunches are delivered, a volunteer brings him dinner a couple of nights a week, his daughter orders groceries, and Donna picks them up before she visits. Doug’s volunteer calls more often, his daughter has gotten a life alert and TCHNetwork continues to check in with him. 

For many people, an in-home assessment can be an intimidating idea. While people often get worried that an in-home assessment will lead to their referral to move to assisted living or a nursing home, the goal and purpose of the in-home assessment are only to get a good sense of what the client needs and how we can best connect them to supports so that they can remain safely at home for as long as possible. Doug’s in-home assessment process opened up the possibility of accessing resources, even when he wasn’t in immediate need. Now, as his needs have become more pressing, his support system is already in place.  

Sheila and Barry 

Sheila, a 75-year-old woman in Norwood, is left alone during the day while her son Barry is at work. The situation feels increasingly dangerous to them.  

When Barry reached out to TCHNetwork to inquire about resources and services for Sheila, Alexis, Care Coordinator at TCHNetwork, conducted an in-home assessment to see how TCHNetwork could help. Together they concluded that Shelia could use the help of a walker to make sure she traveled comfortably around the house and that housekeeping assistance would be helpful. Alexis arranged for home making services, connected Sheila with a walker, and helped her become approved for a life alert in case she was to fall. Now, Sheila and Barry feel more comfortable with their living situation knowing Sheila can safely move around the house while he is at his job.  


TCHNetwork received a called in May about Jane, an 88-year old woman living in the West End of Montrose County. Her son and daughter-in-law are Jane’s only relatives, and they live 3 hours away from Jane. They were worried about Jane getting proper nutrition and staying connected to other people because of the COVID-19 restrictions in place. Jane is very hard of hearing, cannot talk on the phone, and needs things written down so she can read what is being discussed. She also cannot drive or shop for herself, and, because she is on a fixed income, has difficulty paying for her living expenses.  

Alexis, Care Coordinator, set up a time to do a home visit with Jane. Her son and daughter-in-law made the drive in to attend the assessment. The group met and sat on Jane’s porch with masks on, and Alexis discussed programs available to Jane including homemaking, home-delivered meals, life alert, and transportation services. Alexis also went over the qualification for Long-Term Medicaid Waiver programs and Medical and Durable Powers for Attorney. 

Once the family learned about the different programs, they decided to enroll Jane in home-delivered meals, which started within a week. Alexis also worked with Jane to complete a Long-Term Care Medicaid application. Jane is also receiving homemaking help, a free life alert in case she falls, and transportation services now that she is more comfortable going out into the community.  

While it took the COVID crisis for Jane’s family to reach out to TCHNetwork, Jane will continue to receive services beyond the end of the crisis. Her family is relieved to know they have some local back-up in case another crisis occurs and they can’t make the 3-hour drive to get to Jane. 


Daniela became injured and needed a piece of Durable Medical Equipment to borrow for her recovery. Since Daniela only speaks Spanish, she worked with TMC Nurse Ximena who was able to refer her to TCHNetwork’s palliative program. Upon her referral, Multicultural Engagement team members María and Valentina jumped to action to connect Daniela with crutches from TCHNetwork’s inventory of free equipment provided in the short term to anyone who in San Miguel County. With a few quick signatures, María was able to deliver the equipment to Daniela and explain in her own language how to use it.

“TCHNetwork has always been a really, really great resource for things like that – not just Durable Medical Equipment but anything I can’t find the answer to, or that is outside of my medical scope. Someone is always willing to help or facilitate, and it is so important for our community!” stated Ximena.


Sometimes the most meaningful connections don’t involve anything physical at all. This is the case for Amber, Care Coordinator in Montrose County. Amber has been working with Dorry, an older adult who acts as the caregiver for her spouse, whose dementia presents a challenge for the couple. Amber was able to assess Dorry’s needs over the phone and came to realize that she feels very isolated because of COVID and leery about having people in her home. To provide support, Amber calls Dorry weekly to check-in; she has been able to build trust, rapport and emotional support to Dorry in this difficult time. 

Contact us if you need support!

If you would like to learn more about the in-home assessment process, Durable Medical Equipment loaning, or any of the resources mentioned above, please feel free to reach out to Amy at or call our main office at 970 708 7096.  

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