POPULATION HEALTH
MANAGEMENT

To demonstrate our commitment to provide the highest quality patient care, Cano Health has implemented a 24×7 medical urgency line as part of our Cano At Home program. Through our Cano At Home program, we provide home visits to existing patients who have medical urgencies. Our team of health care practitioners is also dedicated to providing home visits for our existing patients with high-risk, complex cases that are enrolled in our care management program.

This is demonstrated through:

• Increased knowledge of PCP and Specialists treatment plan(s) and its adherence
• Increased knowledge of medical condition and associated complications
• Improved self-management skills (proactive) and early identification of exacerbations
• Increased knowledge of benefits and resources for care
• Improved access to needed resources through care coordination assistance
• Decreased hospitalizations and emergency room visits

Telehealth After COPD Hospitalization (TEACH) Program

Cano Health’s TEACH Program (Telehealth After COPDHospitalization), is designed to incorporate both home visits and telehealth, as part of our in-home management of health status for patients with Chronic Obstructive Pulmonary Disorder. Satisfaction with the care a patient is receiving is important in maintaining motivation and treatment compliance. A blend of telehealth and home visits can provide an opportunity to improve patient satisfaction as well as quality of life while potentially reducing readmission costs for patients with COPD. As soon as an eligible patient is discharged from the hospital and enrolled in Cano Health’s TEACH Program, the patient will receive home visits alternated with telehealth monitoring.

Cano Health, through its “high touch” TEACH program is actively enrolling patients and improving the lives of our members by visiting them in their familiar surroundings, at home.

Benefits include:

• Alert the healthcare team if there are sudden changes to the patient’s health
• Evaluate whether a patient has filled their prescription on time or is taking the medication at the appropriate time: improved medication adherence
• Help the patient link behavior or activities to the onset of symptoms
• Provide education to help the patient understand their disease and how to better manage their symptoms
• Improving outcomes and reducing hospital readmissions can be clearly demonstrated and reinforces Cano Health’s commitment to our patients!

The primary goal of our care management team, in collaboration with our primary care physicians, is to improve the overall health and quality of life for our patients through the early identification of needs and coordination of care and services for those patients identified as complex or high-risk.

Cano’s Population Care Managers are onsite at each of our Cano Health Medical Centers, and engage with our members face-to-face whenever possible.

Programs include:

• Disease Management Programs for the following conditions:
  • Chronic Obstructive Pulmonary Disease “COPD”
  • Congestive Heart Failure “CHF”
  • Diabetes
• High Risk & Complex Care Management Programs
• Home Visits for patients with medical urgencies and with high-risk, complex care management cases
• Pre-Enrollment Care Management Assessment Program
• Telehealth After COPD Hospitalization (TEACH Program)
• Transition of Care Programs