Funded through the HRSA: Health Resources and Services Administration
Eligibility
- Patients with chronic conditions who receive care at participating clinics in
- Receive care at participating partners.
- Montrose West End: Basin Clinic, San Miguel County: Uncompahgre Medical Clinic, and Telluride Regional Medical Center. Telluride Whole Health or San Miguel Public Health
Connecting You to the Resources That Support Your Health
Living with a chronic condition like diabetes, heart disease, or depression can be overwhelming, but you don’t have to manage it alone. TCHNetwork’s Pathways Program is here to support you in improving your health and reaching your goals by addressing the everyday challenges that affect your well-being.
What is Pathways?
Pathways is a free, community-based program that connects you to local resources that support your whole health, not just your medical care. Our team helps identify and reduce barriers like access to healthy food, transportation to appointments, or support with housing, stress, or mental health.
How It Works:
You’ll work one-on-one with a Community Health Worker (CHW) assigned to your local clinic. Together, you’ll create a plan that fits your life and health goals. The CHW will check in regularly, help schedule appointments, and follow up on progress.
We Can Help With:
- Food access (pantries, meal boxes, nutrition support)
- Transportation to medical or therapy appointments
- Behavioral health support and connection to therapy
- Housing resources
- Benefit applications and referrals to other TCHNetwork programs
Why Join Pathways?
✔ Personalized support
✔ Local resources
✔ Improved health and confidence
✔ Someone to walk beside you, not ahead of you
The 20 Pathways in the Pathways Model
- Medical Referral – Connecting to a primary care provider, specialist, or clinic.
- Medication Management – Ensuring medications are filled, understood, and taken correctly.
- Dental Referral – Connecting to preventive or urgent dental care.
- Mental Health Referral – Linking to therapy, psychiatry, or counseling services.
- Substance Use Referral – Connecting to substance use treatment or recovery support.
- Health Insurance – Helping enroll in Medicaid, Connect for Health, or OmniSalud.
- Medical Home – Supporting ongoing connection to a consistent provider or clinic.
- Prenatal Care – Connecting pregnant individuals to prenatal services and education.
- Postpartum Care – Ensuring follow-up care and support after delivery.
- Parenting Support – Referrals to parenting classes, home visiting, or child development programs.
- Employment – Support with job readiness, training, or employment opportunities.
- Education – Assistance with GED, ESL, college enrollment, or continuing education.
- Housing – Connecting to emergency shelter, affordable housing, or housing case management.
- Food Security – Linking to SNAP, food banks, meal delivery, or nutrition programs.
- Transportation – Arranging rides or access to public/non-emergency medical transport.
- Utility Assistance – Help accessing programs like EOC, LEAP, or utility shut-off prevention.
- Safety – Support for those experiencing domestic violence, abuse, or unsafe conditions.
- Social Service Referral – Broad referrals to community programs and wraparound services.
- Developmental Referral – Linking children or adults to evaluations or services for disabilities or developmental delays.
- Immunizations – Ensuring access to recommended vaccines for adults or children.
