In November 2018, Rocky Mountain Health Plan’s Medicaid Care Coordinator from a clinic in Durango referred Fred to me. He was moving from Durango to Montrose to be at a lower altitude. Fred has physical disabilities, anxiety, a traumatic brain injury, TBI, forgetfulness when he gets overwhelmed and difficulty following through with multiple tasks at the same time.
Fred’s condo sold in one day. He had to sell and donate all his belongings and kept what could fit in his car. Fred essentially came to Montrose homeless. His goals were were to get established in Montrose with housing, medical primary care, and to learn about resourses.
My role as an outreach coordinator:
- Educate on benefits,supports and services in Montrose.
- Work with him to coordinate with La Plata and Montrose counties to get SNAP (food assistance),Medicaids, OAP (Old Age Pension) benefits switched.
- Assist in scheduling appointments for Medical and Dental.
- Assist in communicating with Social Security for SSDI (Social Security Disability) application.
- Assist in finding stable housing.
- Build trust and rapport.
What Fred and I worked on together.
- Getting a doctor’s appointment scheduled. I went with Fred to his first doctor’s appointment.
- We contacted Social Security in regard to his SSDI appointment.
- We worked to get SNAP and Medicaid moved to Montrose County.
- We filled out housing applications for Area Best Properties and Anciano Towers.
- Transportation and nutrition were not initial goals but quickly became a goal when I figured out after his doctor’s appointment was made. Fred stated he was afraid to drive his car while it was packed. He was also being limited from eating nutrient rich food.
- We contract All Points Transit for medical appointments and Region 10 Area on Aging for transportation vouchers to eat at a congregate meal site and for shopping.
Fred and I have had 12 face to face meeting and multiple phone conversations. Good trust and rapport continue to be built.
Here is a list of agencies we worked with during Fred’s transition.
- Axis, Health Clinic in Durango
- Rocky Mountain Health Plans (RMHP)
- Tri-County Health Network
- La Plata County
- Montrose County
- Health Clinic PIC Place
- All Points Transit
- Region 10 Area Agency on Aging
- Christ Kitcheen
- Montrose Senior Center
- Social Security
- Area Best Properties
- Anciano Towers
- Title Company in Durango
- Networking group for household items
- Hartman Brothers
- Integrated Dermatology
- Mountain View Therapy
- Time Bank of the Rockies
- Outreach to community members for household good donation
Phew, what Fred has accomplished.
- Fred established primary medical care, physical therapy, dermatology and dental in Montrose.
- His benefits transferred to Montrose County from La Plata.
- SSA has been updated on his living situation and he is waiting for final approval.
- Transportation services are established.
- Fred is eating at the Senior Center.
- The best accomplishment is that Fred has moved into his own affordable apartment with the necessities needed to establish a new home.It is exciting that affordable housing was found so quickly with the housing shortage.
Why I love doing what I do.
When I first met with Fred, he had a lot of anxiety and uneasiness, he was very overwhelmed and did not know where to start. After working, empowering and supporting Fred for the past two months, he has gained more confidence, feels more secure and comfortable with his move to Montrose. Thank you to the wonderful people in our community who donated supplies and furniture to Fred which made it possible for him to move with basic necessities to start over. I love our community.