Chronic Disease Management in
Fort Myers & Lehigh Acres
- Adults and seniors
- Fort Myers & Lehigh Acres
- Medicare accepted
- Telehealth available
PrimaryCareIM follows conditions like diabetes, high blood pressure, heart disease, COPD and arthritis over time for adults and seniors at our Lehigh Acres and Fort Myers offices. One primary care team, one place where the whole picture is held.
What is disease management?
Disease management is the ongoing medical care of a health condition you are going to live with for a while, regular visits, testing, medicine review, and adjusting the plan as your health changes.
It is different from being treated once and sent home. The CDC defines chronic conditions as ones that last a year or more and need ongoing medical attention, limit daily activities, or both. Care that lasts a year or more needs a structure, not a series of separate appointments.
At PrimaryCareIM, that structure sits inside your regular primary care. Your provider keeps the record of what your condition is doing over time, what you are taking, what your specialists have said, and what happens next. Nothing extra to enrol in and nothing separate to schedule, it is part of being a patient here.
Acute or chronic, we manage both.
A chronic condition is followed over years. An acute problem (an infection, an injury, a sudden flare of something you already have) is handled now. Our care covers both, and the two are connected: an acute illness often lands on top of a chronic condition, and the plan has to account for that.
Conditions we help manage
These are the long-term conditions we follow most often for adults and seniors in Fort Myers and Lehigh Acres.
Diabetes
High blood pressure
Heart disease
High cholesterol
COPD
Asthma
Arthritis
Kidney disease
Memory changes, Alzheimer’s disease and dementia
Not sure which of these applies to you? You do not need to decide on your own. Call either office and our team will review your needs and explain what may fit. You can also see all primary care services at PrimaryCareIM.
What ongoing care actually looks like here
Managing a long-term condition well is mostly unglamorous: showing up, checking, adjusting. Here is how that works at PrimaryCareIM.
We start with the whole picture
Your first visit covers your history, every condition you are managing, every medicine and supplement you take, your past test results, and which specialists you already see. If your care started somewhere else, we work from those records rather than starting you over.
You leave understanding the plan
Your provider explains what is being watched, what is being treated, what the next test is for, and when you are coming back. If something is not clear, ask again, a plan you do not understand is a plan that will not happen.
Regular visits and lab work on a schedule
How often depends on your condition and how stable it is. The point is that the schedule exists and is followed, so a change shows up at a check rather than in an emergency room.
Medicines reviewed as they change
Prescriptions accumulate from us, from specialists, from a hospital stay. We review the full list, including anything you buy over the counter, and look at how the pieces work together. Please never stop or change a medicine on your own; talk with your provider first, because stopping or changing a medicine without advice can be dangerous and can make a condition worse. Medication management
We stay in touch with your other doctors
Research on primary care describes the primary care physician as the first point of contact and the person who pulls the team together across specialists and community services. In practice that means chasing the cardiologist’s notes, reading the imaging report, and making sure the hospital discharge summary reaches your chart.
The plan changes when you do
A new symptom, a new diagnosis, a hospital stay, a result that moves, any of these can change what your plan should be. It gets revised, not re-photocopied.
Some visits can be done from home
Telehealth visits are available for many follow-ups and check-ins. Ask our team whether telehealth suits the visit you need.
When something changes or flares
Call the office. Do not wait for your next scheduled visit.
Long-term conditions are not steady. Breathing gets harder for a few days, a joint swells, readings drift, a new medicine does not agree with you, or you just feel different in a way you cannot name. Those are the moments a plan gets adjusted, and the sooner we know, the smaller the adjustment usually is.
Value-based care and Medicare
Do not call the office in an emergency. Call 911.
If you have chest pain, trouble breathing, signs of a stroke, severe weakness, fainting, severe confusion, or another emergency symptom, call 911 or go to the nearest emergency department right away. Do not wait for a call back and do not drive yourself.
You keep all your current Medicare benefits.
Why ongoing management matters
High blood pressure usually has no warning signs at all, which is why so many people do not know they have it. A condition that does not announce itself has to be looked for on a schedule.
Long-term conditions are ordinary, not unusual.
The second problem is arithmetic.
Structured chronic care in primary care is a long-established idea, not a marketing one.
Your part in it
Most of what happens to a long-term condition happens between appointments, in your own life. The care team’s job is to make that easier, not to hand you a list of rules.
Health professionals call this self-management support: the organised provision of education and support by health care staff to build patients’ skills and confidence in managing their own health problems, including regular check-ins on progress and problems, setting goals, and help with solving problems as they come up. In plainer terms: we explain, you decide what is realistic, and we adjust together.
Bring everything you take. Prescriptions, over-the-counter medicines, vitamins and supplements, the bottles or a photo of them is easiest.
Bring your home readings if you take any. Blood pressure, blood sugar, weight. Even rough notes help.
Say what is actually happening. If you have not been taking something, say so. Nobody is going to be cross. A plan built on what is really happening works better than one built on what should be happening.
Bring your questions written down. Three is plenty. Appointments move fast and good questions get forgotten.
Tell us about side effects early. There is often another option, but only if we know.
Do not stop or change a medicine on your own. Talk with your provider first, stopping or changing a medicine without advice can be dangerous and can make a condition worse.
Bring someone with you if it helps. A spouse, an adult child, a caregiver. Two people remember more than one.
Who this is for
If any of these sound like you, this is the kind of care we mean.
You have been managing a condition for years and want a primary care team that actually keeps track of it
You were recently in the hospital, a rehabilitation facility or the emergency department
You are managing two or three conditions at once and the pieces do not talk to each other
You are a Medicare patient who wants closer follow-up than occasional visits give you
You take several medicines and would like one person looking at the whole list
You are caring for a parent with several conditions and trying to keep it all organised
You were recently diagnosed with something and are not sure what happens next
You have moved to Southwest Florida and need someone here to take over care that was set up elsewhere
You see specialists and want a primary care doctor holding the overall plan
You do not have to sort out which service you need before you call. That is what the first visit is for. Depending on where you are in life, start with adult primary care or senior and geriatric care.
Disease management, Chronic Care Management and Medicare
These sound like the same thing and they are not. Here is the difference in plain terms.
Disease management
Clinical care
Chronic Care Management (CCM)
A specific Medicare service
Advanced Primary Care Management (APCM)
A newer Medicare option
WHAT IT IS
Disease management
The medical care of your condition, your visits, your testing, your medicines, your plan
Chronic Care Management (CCM)
A named Medicare service delivered monthly on top of your visits
Advanced Primary Care Management (APCM)
Several existing Medicare care management services brought together into one monthly service
What it involves, and what it costs
Disease management
Nothing to enrol in, nothing to sign, and no separate monthly charge. Visits are billed the way any office visit is billed
Chronic Care Management (CCM)
An agreement to receive the service monthly. After you meet the Part B deductible, you pay coinsurance
Advanced Primary Care Management (APCM)
Your consent, recorded in your chart. Cost sharing may apply
Disease management is clinical care
It is the medical care of your condition, your visits, your testing, your medicines, your plan.
It is part of being a primary care patient at PrimaryCareIM. There is nothing to enrol in, nothing to sign, and no separate monthly charge for it. Your visits are billed the way any office visit is billed.
Chronic Care Management is a specific Medicare service
Chronic Care Management, usually shortened to CCM, is a named Medicare service delivered monthly on top of your visits.
Medicare says you must have two or more serious chronic conditions that are expected to last at least a year in order to qualify. The service includes a comprehensive care plan, round-the-clock access for urgent care needs, support during care transitions, and review of your medicines.
Two things to know before you agree to it. Your provider will ask you to sign an agreement to receive the service on a monthly basis. And after you meet the Part B deductible, you pay coinsurance for it.
Advanced Primary Care Management is a newer Medicare option
Advanced Primary Care Management, or APCM, brings together elements of several existing Medicare care management services: chronic care management, care for a single complex condition, follow-up after a hospital stay, and technology-based check-ins, into one monthly service.
It requires your consent, which is recorded in your chart, and that consent has to tell you that only one provider can be paid for it in a given month and that cost sharing may apply.
What this means for you
You get disease management here either way.
The Medicare programmes are optional extras for people who qualify and who want the additional monthly support. If you are eligible for one, we will explain it, tell you about any cost, and ask before anything starts.
Medicare Advantage plans and secondary insurance work differently from Original Medicare. Please check your own coverage with our office and with your plan before you agree to any monthly care management service. You can also see the insurance plans we work with.
Services that work alongside this
Managing a condition rarely sits on its own. These are the other parts of your care at PrimaryCareIM.
Primary Care
The regular office visits everything else is built around.
Medication Management
Review and coordination of your medications as your treatment changes.
Chronic Care Management
You are seen when you call with a problem
Annual Wellness Visits
A yearly planning visit focused on prevention and personal health goals.
Physical Exams
Yearly exams to review overall health and preventive needs.
Care Coordination
Help with referrals, records, test results and follow-up across your providers.
Remote Patient Monitoring
Connected devices that share certain health readings from home with your care team, for eligible patients.
Transitional Care Management
Follow-up in the period after a hospital or qualifying facility discharge.
Advanced Primary Care Management
A Medicare service adding structured care planning, coordination and support between visits for eligible patients.
Not sure which of these you need? You do not have to work it out alone. Call either office and we will go through it with you. You can also see all primary care services at PrimaryCareIM.
Chronic disease management in Fort Myers and Lehigh Acres
Fort Myers Office
Lehigh Acres Office
Telehealth visits are available for many follow-ups and check-ins. We accept Medicare and work with major insurance providers, see the insurance plans we work with or call and we will check for you.
Insurance and coverage
PrimaryCareIM works with Medicare, many Medicare Advantage plans, and a range of major insurance providers.
Insurance plans we work with
What patients say
“Great appointment. On time, thorough, totally professional and a wonderful helpful front office.”
Fort Myers Patient
“Excellent service, as always. From check-in to check-out, everyone is very friendly and efficient. Thank you.”
Lehigh Acres Patient
Frequently asked questions about value-based care
What is disease management?
Disease management is the ongoing medical care of a health condition you will live with for a while: regular visits, testing, review of your medicines, and adjusting the plan as things change.
The CDC defines chronic conditions as ones that last a year or more and need ongoing medical attention, limit daily activities, or both. At PrimaryCareIM this is part of regular primary care for adults and seniors in Fort Myers and Lehigh Acres, with nothing separate to enrol in.
Which conditions does PrimaryCareIM manage?
We follow long-term conditions including diabetes, high blood pressure, heart disease, high cholesterol, COPD, asthma, arthritis, kidney disease, and memory changes including Alzheimer’s disease and dementia.
We also treat acute problems such as infections and flare-ups of a condition you already have. This is not a complete list , call the Fort Myers office at 239-489-0800 or Lehigh Acres at 239-369-9911 and ask about your condition.
Can one primary care doctor manage more than one condition at a time?
Yes, and that is one of the main reasons to have a primary care practice.
Managing several conditions together means looking at how the medicines interact, how one condition affects another, and what each specialist has recommended. Research on primary care describes the primary care physician as the first point of contact and the person who coordinates care across specialists and community services.
Do I still need my specialist?
Usually yes.
A specialist goes deep on one condition; your primary care team holds the whole picture and keeps the parts connected. The two work together. We read what your specialists send, we keep your record current, and we make sure a change made in one place is known about in the other.
What should I bring to my first visit?
Bring everything you take: prescriptions, over-the-counter medicines, vitamins and supplements, or a photo of the bottles.
Bring any home readings you keep, such as blood pressure or blood sugar. Bring a short written list of questions, and bring a family member or caregiver if that helps you remember. If your care started with another practice, bring what records you have or tell us where they are.
What should I do if my condition flares up between visits?
Call the office rather than waiting for your next appointment: Fort Myers 239-489-0800, Lehigh Acres 239-369-9911, Monday to Thursday, 8:00 AM to 5:00 PM.
Changes are usually easier to deal with early. If you have chest pain, trouble breathing, signs of a stroke, severe weakness, fainting, severe confusion or another emergency symptom, call 911 or go to the nearest emergency department right away.
What is the difference between disease management and Chronic Care Management?
Disease management is the clinical care of your condition (visits, testing, medicines and the plan) and it is part of being a primary care patient, with nothing to sign up for.
Chronic Care Management is a specific Medicare service delivered monthly in addition to your visits. Medicare says you must have two or more serious chronic conditions expected to last at least a year to qualify, your provider will ask you to sign an agreement, and after you meet the Part B deductible you pay coinsurance for it.
Does Medicare cover chronic disease care?
Your regular office visits are billed the way Medicare bills any primary care visit.
Separately, Medicare offers monthly care management services for people who qualify. For Chronic Care Management, Medicare says you need two or more serious chronic conditions expected to last at least a year, you sign an agreement, and after the Part B deductible you pay coinsurance. Advanced Primary Care Management also requires your consent and may involve cost sharing. Medicare Advantage and secondary plans differ, so check with our office and your plan.
Do I have to sign up for anything to get disease management here?
No. Disease management is part of ordinary primary care at PrimaryCareIM.
The only things that require a signature or consent are the specific Medicare monthly care management services, and those are optional. You will be told what they involve and what they may cost before anything starts, and you can stop taking part at any time.
Can some of my follow-up visits be done by telehealth?
Often, yes. Telehealth visits are available for many follow-ups and check-ins.
Some things still need to be done in person — an exam, blood work, certain tests. Ask our team which applies to the visit you need.
I was just diagnosed. Where do I start?
Start with one appointment.
Bring your diagnosis, any test results you have, and every medicine you take. The first visit is mostly listening and mapping: what the condition is, what is already being done, what needs watching, and when you come back. You do not have to understand it all before you walk in.
How do I start with PrimaryCareIM in Fort Myers or Lehigh Acres?
Call the office nearest you (Fort Myers at 239-489-0800 or Lehigh Acres at 239-369-9911) or book an appointment online.
Your first visit reviews your health history, your medications and your current providers, and from there your provider can explain which ongoing services may fit.
Let’s get your care on a steadier footing
If you are managing a long-term condition and it feels like you are the one holding it all together, you should not have to be. Call the office closest to you and our team will help you find a time.
New patients are welcome at both our Lehigh Acres and Fort Myers offices.