Open logic model templates for 20 program types.

Inputs

• 1.0 FTE certified diabetes care and education specialist (CDCES) and 0.5 FTE bilingual community health worker
• EHR diabetes registry built from the health center's UDS Table 7 extract
• ADCES-accredited or ADA-recognized DSMES program curriculum and licensing
• Glucometers, test strips and food-model kits for 340 enrollees
• Evening and Saturday classroom space at two clinic sites plus a telehealth platform

Activities

• Run monthly registry pulls to flag patients with HbA1c above 9% and assign outreach to the CHW
• Deliver an 8-session DSMES curriculum in English and Spanish, in person and by video
• Hold warm handoffs from primary care visits to the CDCES on the same day
• Provide medically tailored grocery vouchers through a partner food bank for food-insecure enrollees
• Review each enrollee's HbA1c at 3 and 6 months with the care team

Outputs

• 1,150 high-risk patients contacted through registry outreach each year
• 312 adults complete the 8-session DSMES curriculum each year
• 96 cohort sessions delivered, at least 40% in Spanish
• 280 enrollees receive a same-day warm handoff from their primary care provider

Short-term

• 80% of completers demonstrate correct glucose self-monitoring technique at session 8
• 70% of completers set and track a written self-management goal
• Diabetes self-efficacy scores rise by at least 1 point on a 10-point scale

Intermediate

• Mean HbA1c among completers falls by 0.8 percentage points at 6 months
• Share of the health center's diabetic patients with HbA1c above 9% falls from 31.4% to 26% within 2 years
• Diabetes-related ED visits among completers drop by 15% year over year

Long-term

• Fewer diabetes complications (amputations, retinopathy, kidney disease) in the service area
• DSMES becomes a billable, sustained service line covered by Medicare and Medicaid reimbursement