Chronic Care Management in Florida: CCM Services Explained

What Conditions Qualify for Chronic Care Management in Florida?

Being diagnosed with a chronic condition such as diabetes or hypertension can feel overwhelming and confusing. You probably have a million questions, like how it will affect your lifestyle or your family, or how much treating it will cost.

But your primary care provider (PCP) is here to help, ensuring you won’t have to walk this new journey alone.

PCPs offer chronic care management (CCM), providing you with the support, resources and tools you need to make managing a chronic condition as trouble-free as possible.

Chronic Care Management in Florida

When you or a loved one receives a diagnosis of a chronic health condition such as Type 2 diabetes or chronic obstructive pulmonary disease (COPD), you’ll learn what’s involved in managing the condition, such as patient education, medication and lifestyle changes. Many patients can successfully manage a single chronic condition on their own with support from their primary care team.

Unfortunately, it’s not uncommon for patients with one chronic disease to develop another. Researchers estimate that about half of all adults in the U.S. with a chronic illness will develop a second one during their lifetime.

While managing one chronic disease is doable, managing two or more can be difficult. This is where CCM with your primary care provider helps.

What Is Chronic Care Management?

In the simplest terms, CCM supports patients who have two or more chronic health issues that are both expected to last for 12 or more months.

Not only does primary care chronic disease management help patients prevent complications from their conditions, but it also improves quality of life and reduces hospital visits.

CCM services are facilitated and coordinated by your primary care provider (PCP), rather than being given in a single visit, as with a procedure.

Here’s how it works:

• Health screening services: Based on your annual wellness exams, bloodwork and physical exam results, your PCP may conduct or recommend additional health screenings throughout the year, such as heart health screenings. This helps your care team monitor existing health concerns and potentially identify new ones.
• PCP-led coordination: Your primary care provider may have been the one to diagnose your condition, and they’ll continue to act as the central point for your care. Through ongoing care and comprehensive primary care services, they’ll continue to oversee your overall care plan, lab results, track your medications and monitor your progress.
• Team-based support: CCM often involves nurses, care coordinators and other clinical staff who help with regular check-ins, patient education and monitoring. Your PCP ensures all aspects of your care are connected.

CCM services do this through:

• A collaborative health care team effort, all coordinated through your primary care team, bringing in specialists, therapists, caregivers and other health care professionals.
• A fully personalized care plan that is customized to your specific health needs.
• Consistent monitoring of your chronic conditions through multiple check-ups during the year.
• Guidance on lifestyle changes, such as diet, exercise and stress management.
• Medication management
• Robust patient education that teaches what you and your family can do to help self-manage your conditions.

The Importance of CCM for Your Health

There are many benefits that CCM can provide for a patient with two or more chronic conditions, including peace of mind knowing your entire health care team is staying connected and proactive.

Other benefits include the following:

• Empowered patients who can take charge of managing their disease through full support and education
• Improved disease management through consistent health monitoring and medication assistance
• Lowered chance of developing complications or worsening of symptoms
• Reduced risk for emergency room visits and hospitalizations

Core Eligibility Criteria for Chronic Care Management

Two main sets of criteria can make you eligible for CCM assistance.

1. The "Two or More Chronic Conditions" Rule

The first criterion for receiving CCM services is that the patient must have received a diagnosis of two or more chronic conditions expected to last 12 months or more.

For example, if you were diagnosed with Type 2 diabetes last year and then this year you received a diagnosis for arthritis, then you may qualify for CCM.

Additionally, your chronic conditions must be serious enough that they increase your risk of dying, body organ or system failure, or the inability to live your daily life without assistance.

2. The Requirement for a Comprehensive Care Plan

If you or a loved one meets the criteria for CCM services, the next step is for your health care team to develop a comprehensive care plan tailored to your specific health needs.

This care plan serves as the main map to help you and your medical team navigate your health care journey, keeping everyone working towards the same goal.

Your personalized care plan will include:

• Details of your customized care needs and how they will be addressed
• Health-related goals with any associated timeframes or details
• Names and information on all doctors, nurses, specialists and therapists that make up your CCM care team
• Outline of all medications and therapies to be prescribed
• Plan for accomplishing daily activities, especially if assistance is needed
• Who to contact for emergencies

It's important to remember that your personalized CCM plan is not set in stone — it will be regularly reviewed and updated by your health care team as your needs change.

Common Chronic Conditions That Qualify for CCM Services in Florida

What conditions qualify for chronic care management? Quite a few.

Examples include the following:

• Age-related macular degeneration (AMD)
• Anemia
• Arthritis
• Asthma
• Atrial fibrillation
• Autism spectrum disorder (ASD)
• Cancer
• Cataract
• Cerebral palsy
• Chronic kidney disease
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure
• Coronary artery disease
• Cystic fibrosis
• Dementias such as Alzheimer's disease
• Depression or other mental health conditions
• Diabetes
• Diabetic retinopathy
• Emphysema
• Epilepsy
• Fibromyalgia
• Glaucoma
• Heart disease
• Hepatitis B and C
• High blood pressure (hypertension)
• High cholesterol (hyperlipidemia)
• HIV/AIDS
• Hypothyroidism
• Irritable bowel disease (IBD) such as Crohn’s disease or ulcerative colitis
• Liver disease
• Migraine or chronic headaches
• Multiple sclerosis
• Obesity
• Osteoporosis
• Parkinson's disease
• Post-traumatic stress disorder (PTSD)
• Sickle cell disease
• Sleep apnea
• Stroke
• Substance use disorders
• Tinnitus
• Traumatic brain injury (TBI)
• Vertigo

Keep in mind that this isn’t a complete list of all the chronic health conditions that qualify for CCM. Talk to your primary care provider about your health conditions.

Providing Full Support for Chronic Care Management

Chronic conditions aren’t always easy to live with and manage. The good news is that you don't have to go it alone. CCM services can provide you with the guidance, support and whole-person care you need to make your life a little bit easier.

Schedule an AdventHealth Primary Care+ appointment today to discuss your ongoing health needs and find out if you qualify for chronic care management.