Care Management Services in Montrose, CO

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Seniors Blue Book

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Jul 13, 2026

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Managing the needs of an older adult can become complicated quickly. A family may be coordinating primary care, specialists, medications, transportation, personal care, therapy, meals, and several providers are involved, important details can be missed, appointments may overlap, and family caregivers can feel as though they are carrying the entire system on their shoulders.

Care management services help bring those moving parts together. In Montrose, one option for eligible older adults is Senior CommUnity Care, Western Colorado's Program of All-Inclusive Care for the Elderly, commonly called PACE. Rather than offering only one isolated service, the program coordinates medical care, long-term support, social services, and practical assistance through one organized care plan.

This guide explains what care management means, who may benefit, how PACE-based coordination works, and what families should know when considering Senior CommUnity Care in Montrose, Colorado.


What Are Care Management Services?

Care management is a structured approach to assessing a person's needs, creating a plan, arranging services, monitoring changes, and adjusting support over time. The goal is to make care more organized and responsive to the whole person, not just a single diagnosis or appointment.

A care manager may help identify gaps, communicate with health professionals, connect a family with community resources, support transitions after hospitalization, and monitor whether the current plan is still working. Depending on the program, care management can include medical coordination, medication review, home safety support, transportation planning, caregiver education, and help accessing benefits.

Who May Benefit From Care Management?

Care management may be helpful when an older adult has multiple chronic conditions, takes several medications, has had repeated hospital or emergency visits, needs help with daily activities, or is showing changes in mobility, memory, nutrition, or mood. It can also be valuable when family members live far away, disagree about next steps, or are struggling to coordinate care while managing work and other responsibilities.

Not every person needs the same level of support. Some families need occasional guidance, while others need a comprehensive program that can coordinate nearly every aspect of care. Senior CommUnity Care falls into the second category. Its care management is part of the broader PACE model and is available to people who meet PACE eligibility requirements.


Senior CommUnity Care - Western Colorado's PACE Provider

Phone: 970-964-3500

PACE is a Medicare and Medicaid program that helps eligible adults age 55 and older receive coordinated medical and social services while continuing to live in the community. Participants must live in an approved service area, need a nursing facility level of care as certified by the state, and be able to live safely in the community with PACE support at the time of enrollment. model uses an interdisciplinary team. Instead of asking the participant or family to coordinate every provider independently, the team evaluates needs, develops a care plan, arranges approved services, and reviews the plan regularly. The program can cover primary care, specialty care, prescription drugs, hospital services, home care, therapies, personal support, social services, transportation, and other services the team determines are medically necessary. more than a referral service. Once enrolled, the PACE organization becomes the participant's primary source for covered care and services. Families should understand this structure before enrolling because nonemergency care obtained outside the program without approval may not be covered. r CommUnity Care Western Colorado's PACE Provider

Senior CommUnity Care of Colorado operates a PACE center at 2377 Robins Way in Montrose and serves eligible older adults in Montrose and Delta Counties. The program is designed for people who want to remain at home but need a higher level of coordinated support. management approach combines health care, long-term services, in-home assistance, transportation, social engagement, and caregiver support. Social workers provide case management, while the broader interdisciplinary team coordinates the participant's medical, functional, emotional, and practical needs. vidual Assessment and Care Planning

The process begins with an assessment of the participant's health, daily routines, home situation, personal goals, and support system. The interdisciplinary team uses that information to build an individualized plan rather than applying the same package of services to every participant.

Senior CommUnity Care states that care plans are reviewed every six months, or more often when needed. This ongoing review matters because an older adult's needs may change after a fall, hospitalization, new diagnosis, medication change, or decline in mobility. The team can reassess the situation and adjust approved services when appropriate. cal and Specialty Care Coordination

Participants can receive primary care through the PACE clinic, and in many cases may be able to continue with a current primary care physician if that provider contracts with the program. Senior CommUnity Care also coordinates nursing care, specialty services, laboratory work, X-rays, surgery, emergency care, hospitalization, nutrition services, and other approved medical needs.

Nursing support is available around the clock, including nights, weekends, and holidays. This provides participants and caregivers with a clear point of contact when questions arise outside normal office hours.

Medication Management

Medication coordination is especially important for older adults who take several prescriptions or have difficulty managing schedules, refills, and instructions. Senior CommUnity Care provides medication oversight, home delivery, reminders, and assistance with multiple medications. Approved prescription and nonprescription drugs are managed through the program.

This centralized approach can help the care team see the complete medication picture and communicate about possible concerns, changes, or adherence challenges. ome Support and Safety

Care management is most effective when it addresses what happens between clinic visits. Senior CommUnity Care can arrange approved in-home services such as skilled home health care, bathing and dressing assistance, medication help, meal preparation, and light housekeeping.

The program also offers physical, occupational, and speech therapy. Home visits and modifications may be used to improve safety and daily function. When approved by the interdisciplinary team, durable medical equipment and supplies may also be included, such as canes, walkers, wheelchairs, incontinence products, or nutritional supplements. sportation and Access to Care

Transportation can become a major barrier when an older adult no longer drives or needs physical assistance entering and leaving a vehicle. Senior CommUnity Care provides door-to-door transportation to the PACE center and specialty medical appointments as part of an approved care plan.

By coordinating transportation with appointments and center services, the program can reduce the number of separate arrangements a family caregiver must make. al Support, Activities, and Caregiver Relief

Health is influenced by more than medical treatment. Senior CommUnity Care offers weekday meals, therapeutic recreation, social activities, mental health services, grief support, spiritual support, and help connecting with additional resources.

For family caregivers, the program may provide respite stays and practical relief from some daily coordination responsibilities. The care team does not replace the family's role, but it can reduce the burden of managing every appointment, service, and follow-up alone. ibility and Costs

To enroll in PACE, an individual generally must be at least 55 years old, live in the program's service area, qualify for a nursing facility level of care, and be able to live safely in the community with support. pend on Medicare and Medicaid eligibility. Senior CommUnity Care states that participants who qualify for Medicaid, including those eligible for both Medicare and Medicaid, do not pay a PACE premium. Medicare-only participants may have a monthly premium and Part D-related cost, while a private-pay option may be available for people who do not qualify for either program. The enrollment team can explain the amount, coverage rules, and application process based on the individual's situation. are Management Matters Locally


How to Get Started

  1. Call Senior CommUnity Care at 866-961-1451 and request information about PACE enrollment in Montrose or Delta County.
  2. Confirm that the older adult lives within the current service area. Service boundaries can change, so verify the home address directly with the enrollment team.
  3. Prepare a current medication list, diagnoses, physician contacts, recent hospital or rehabilitation records, and a summary of daily living needs.
  4. Discuss safety at home, including falls, mobility, bathing, meal preparation, memory concerns, nighttime needs, and caregiver availability.
  5. Ask how the state nursing facility level-of-care assessment is completed and what documentation is required.
  6. Review Medicare, Medicaid, and private-pay information carefully. Ask which services require interdisciplinary team approval and how outside providers are handled.
  7. Meet with the intake team and involve the older adult in the decision. PACE should support the person's goals, preferences, and desire to remain in the community.

 

Related Categories

·      Medicare and Medicaid Information

·       Caregiver Support Services

·       Transportation Services

 

This article was researched and written by Seniors Blue Book. Seniors Blue Book connects seniors, families, and caregivers with trusted local senior care resources across the country. Browse local listings, read expert articles, and order a free printed guide at seniorsbluebook.com.

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