Care Coordination

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

Whole Person Health- Why health is more than healthcare

At Tri-County Health Network, we know that a person’s health is made up of a variety of factors, all of which need to be addressed for that person to have the opportunity and ability to thrive. We take a whole-person approach to health that allows us to identify and address underlying factors that may impact a person’s ability to live as healthfully as possible.

Using this approach, TCHNetwork offers programs and services that address social determinants of health, behavioral and mental health, physical health, and clinical care. Our Care Coordination team ensures that community members are supported in navigating disparate resources in a coordinated fashion. We look at all the challenges a community member is experiencing and set long-term goals and develop plans to address these needs. Our jointly developed care plans incorporate and build upon an individual’s strengths and natural supports.

This approach creates a sense of empowerment and sustainable changes for community members.

Social Determinants of Health

We believe that health is more than the healthcare services a person receives from their doctor. This belief is grounded in research that shows people’s health outcomes are impacted by a variety of factors outside of the clinical walls, known as the Social Determinants of Health, (SDoH) which include, but are not limited to an individual’s ability to purchase food and to pay for utilities, their housing situation, their access to transportation as well as their mental health status, socioeconomic status, race, gender, and education level. 

If a person does not have a steady income, they probably do not have stable housing or the ability to buy food. They may be making tough choices every day. Decisions such as do they pay rent or buy insulin? Do they have access to fresh fruits and vegetables at the grocery store and the time to cook a healthy meal at home, or should they just grab some cheap fast food before they head to their second job?

While community health workers, care coordinators and clinicians screen for social determinants of health, it’s the care coordination team that works individually with people to help them access and navigate resources, ensuring they can meet their healthcare goals and lead vibrant lives.

AHCM (Accountable Health Communities Model) 

Recognized as a thought leader on health equity and known to have established relationships with local medical providers, Rocky Mountain Health Plans asked TCHNetwork to act as the Community Lead in Delta, Montrose, San Miguel, Ouray, and Gunnison counties for the Western Slope Accountable Health Communities Model (AHCM) project, which began in 2016.

Since that time, we have worked with local medical providers to adopt and implement the SDoH screening tool. The screening tool consists of 20 questions that help identify patients’ social needs that may not be met. These questions help assess a patient’s basic social needs (i.e. food, housing, transportation) on a more comprehensive level. The outcomes help to determine barriers to care patients may be experiencing.

Additionally, TCHNetwork has developed a directory of community resources that is utilized by our partner clinics to connect patients to the appropriate resources either at low-cost or for free. The guide covers resources in Montrose, Ouray, San Miguel, and Delta counties is available in both English and Spanish, and has been shared with our clinic and community-based organizations partners. To date, our partner clinics have screened over 10,000 patients. TCHNetwork utilizes the AHCM SDoH screening tool as well for our healthcare-related programs and we connect clients to community resources to address identified needs.

Program History

West End Senior Services Collaboration 

TCHNetwork started providing community-based, non-medical care coordination services in 2015, when asked to join the newly formed West End Senior Services Collaboration. Our team of Options Counselors conducted in-home assessments and provided access to the resources needed to help older adults remain living independently in their community.  

ADRC (Aging & Disability Resources of Colorado)  

Based on our successful participation in the Collaboration, TCHNetwork earned the designation as ADRC (Aging & Disability Resources of Colorado) for our region in 2016. Under this program, our scope broadened to include more services to offer to a wider array of community members. We began providing in-home options, benefits counseling, coordination, and referrals to long-term services and supports – assisting adults age 60 and over, adults with a disability or chronic condition, and their caregivers. 

If you know someone who could benefit from an in-home assessment and/or benefits counseling, please complete our support services referral form

Palliative Support Services  

Complementing our work as the ADRC, TCHNetwork launched the palliative support program in San Miguel County in order to fill the unmet need for end of life hospice services in our area. The goals are similar – providing community members with the support they need to live their entire lives in their own homes. Our palliative program is offered to community members who are living with an acute or chronic condition, recovering from an accident, in need of support during end of life or to provide respite to caregivers.

TCHNetwork can assess and connect community members to volunteer help and resources as well as loan out durable medical equipment to help you remain as independent as possible. If you or someone you know needs assistance with groceries, errands, home care, companionship, or a break from caregiver duties, please complete our support services referral form.

We are actively recruiting volunteers to help with our palliative support program. If you are interested in volunteering please complete our volunteer form. To learn more please contact our Palliative Support Services Manager at 970.614.7311 or email oc-montrose@tchnetwork.org.

Care Coordination for Medicaid patients 

Due to our commitment to health equity and a local, community-based approach to health care, RMHP selected TCHNetwork as its partner to provide care coordination to over 13,000 Medicaid members throughout Montrose, Ouray, and San Miguel Counties in 2018. 

Community Care Coordinators help clients in broad ways ranging from navigating the following social determinants of health resources:

  • Connecting with providers
  • Transportation
  • Food
  • Utilities
  • Housing
  • Personal safety
  • Isolation

These clients are referred to us by doctors’ offices, hospitals, Medicaid, and our clinic and agency partners.  If you or someone you know needs care coordination services, please complete our support services referral form.

What’s Next?

In 2020, TCHNetwork was awarded a grant from Health Resources & Services Administration (HRSA) to add an additional non-Medicaid Care Coordinator in the West End of Montrose County. This care coordination is for adults who have complex needs and is modeled after high-fidelity wrap around services for youth. Wrap Around care coordination focuses on a team-based planning process to support clients’ and/or families’ strengths and needs to achieve their goals. Wrap Around is based upon a process of unconditional care – no blame, no shame.

While this program is being piloted in the West End, our intention is to expand to additional service areas in the future. If you or someone you know could benefit from Wrap Around care coordination please contact our Wrap Around Care Coordinator at 970.765.8336 cc-we@tchnetwork.org.

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