Healthcare
FQHC Diabetes Self-Management Education and Support logic model
Across three health center sites, 31.4% of adult patients with diabetes had a last HbA1c above 9% or no test in the measurement year, and fewer than 1 in 10 had ever completed a structured self-management curriculum. Patients cite work schedules, transportation and language as the main barriers.
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 outcomes
- 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 outcomes
- 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 impact
- Fewer diabetes complications (amputations, retinopathy, kidney disease) in the service area
- DSMES becomes a billable, sustained service line covered by Medicare and Medicaid reimbursement
Indicators and data sources
| Indicator | Source | Frequency |
|---|---|---|
| Percent of patients 18-75 with diabetes whose last HbA1c is above 9% (CMS122) | HRSA Uniform Data System (UDS) Table 7 and EHR registry | Monthly internal, annual UDS submission |
| DSMES curriculum completion (8 of 8 sessions) | DSMES program attendance log in EHR | Monthly |
| Change in HbA1c at 3 and 6 months post-enrollment | EHR lab results | Quarterly |
| Diabetes self-efficacy score | Stanford Diabetes Self-Efficacy Scale, pre and post | Per cohort |
| Diabetes-related ED visits | Health information exchange encounter alerts | Quarterly |
Assumptions
- Patients can attend evening, weekend or video sessions once transportation and language barriers are addressed
- Primary care providers adopt the same-day warm handoff protocol
- Medicare and Medicaid DSMES billing remains available to sustain the program after the grant
Programs this model suits
- HRSA Health Center Program (Section 330) quality improvement and expansion supplements
- State health foundation chronic disease prevention grants
- Health plan community reinvestment and quality incentive funds
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