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Rural Health Information Hub

Tri-County Health Network

  • Project Title: Integrated Patient Health Navigators
  • Program Representative Interviewed: Rasa Kaunelis, Grants & Evaluation Administrator
  • Location: Telluride, CO
  • Program Overview: The Integrated Patient Health Navigators program at the Tri-County Health Network, which serves San Miguel, Montrose, and Ouray Counties in Colorado, is integrating patient health navigators as part of a care coordination program to help patients manage their chronic diseases, particularly heart disease and diabetes, and related social needs. Patient health navigators offer a range of support to patients for as long as they need, including health and nutrition education, check-ins between healthcare appointments, and warm handoffs to additional services as needed.

    When hiring patient health navigators, the Tri-County Health Network seeks out potential candidates who are from the community and may even have a chronic disease themselves. Patient health navigators receive training on social determinants of health, community resources, and how to engage patients. Through close partnerships with three local clinics, the patient health navigators are fully integrated into the patients' clinical teams. These critical partnerships allow patient health navigators to attend huddles with the patients' healthcare providers and access patients' medical information.

    The patient health navigators are also linked to the FoodRx Program that helps address food insecurity and improve access to healthy foods in the community. Participants in the FoodRx Program receive $120 vouchers over seven weeks that can be used to buy fruits and vegetables at local food retailers. Participants also receive coaching from the Patient Health Navigators on how to stretch their FoodRx dollars and best incorporate fresh fruits and vegetables into their diets.

Theories, Models, and Strategies Represented by this Program: