Twelve Weeks, Tuesday at 10 a.m.
Riverside Community Health Center, a federally qualified health center with three sites, serves 9,400 patients; 1,180 adults have type 2 diabetes and 38% of those have an A1c above 9%. The center holds a 12-month, $75,000 state foundation grant that is renewable only if the program shows measurable outcomes. Staffing is two certified diabetes care and education specialists at a combined 0.6 FTE, two community health workers hired six weeks ago, and medical assistants with 30% annual turnover. Sixty percent of patients prefer Spanish, and many work in stone-fruit harvest from May through September. The chief medical officer wants a 12-week group class at the main site on Tuesdays at 10 a.m., 25 participants per cohort, three cohorts in the year. A previous English-language series at the same time drew 6, 4, and 3 participants and lost 70% of attendees by week four.
1. Using a planning model, identify the flaws in the proposed plan and the factors that actually drive attendance and glycemic control.
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Run the plan through PRECEDE-PROCEED and it fails at the diagnosis stages, not the delivery stage.
Social and epidemiological diagnosis. The stated need is A1c above 9% in 38% of 1,180 adults. But the objective written so far is program delivery (three cohorts), not health change. Those are different levels in the logic model and must not be confused.
Behavioral and environmental diagnosis. The plan names no behaviors and no environment. Relevant behaviors might include medication taking, glucose monitoring, and meal pattern; relevant environmental factors include food cost, shift work, transport, and clinic scheduling. The prior series' 70% attrition by week four is itself diagnostic data: the intervention did not fit the population's life, and repeating the format predicts repeating the result.
Educational and ecological diagnosis. 10 a.m. Tuesday excludes harvest workers and most hourly employees; English delivery excludes 60% of the target; 12 weeks asks for a 12-week commitment from people with unstable schedules. Predisposing factors (fatalism about diabetes, fear of insulin), enabling factors (transportation, Spanish materials, child care), and reinforcing factors (family, provider follow-up) are all unaddressed.
Administrative and policy diagnosis. 0.6 FTE of diabetes educators cannot run three 25-person cohorts plus follow-up. Two CHWs hired six weeks ago are an asset but not yet trained or integrated. Thirty percent MA turnover means any workflow that depends on MAs will break.
Redesign follows: shorter cycle (6 sessions plus boosters), Spanish-first delivery with interpretation available for English speakers, evening or Saturday options, CHW-led telephone outreach and home follow-up, and a warm handoff from the prescriber at the point of the elevated A1c result rather than a mailed class flyer.
2. Write one process objective and one outcome objective that are measurable within 12 months, and justify the wording.
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Process objective. By month 9, 60% of the 180 adults with an A1c above 9% who are identified in the registry will complete at least 5 of 6 diabetes self-management sessions, with completion tracked by language, site, and insurance status.
Why it is written this way: it names a numerator (completers), a denominator drawn from a defined registry, a threshold, a date, and a stratification. The stratification is the key move - an aggregate 60% could hide 80% completion among English speakers and 30% among Spanish speakers, which is exactly the failure mode of the previous series. Five of six sessions, not all six, sets a realistic completion standard consistent with dose-response evidence in self-management education.
Outcome objective. By month 12, the proportion of program participants with an A1c above 9% will fall from 38% to 30%, measured by the most recent lab value in the electronic health record for all registry patients, regardless of program participation.
Why it is written this way: the denominator is the full registry rather than completers only, which prevents the classic error of reporting improvement only among the people who showed up. It uses an existing EHR measure so it costs nothing extra to collect and cannot be gamed by selective reporting. Twelve months is long enough for two or three A1c draws at the usual three- to six-month interval. It is deliberately modest - an eight-point absolute reduction - because a 12-month grant with 0.6 FTE cannot plausibly deliver more, and an inflated target invites a credibility problem at renewal.
Add a third, short-term indicator for the funder's mid-year report: percentage of referred patients reached by a CHW within 14 days.
3. How would you build sustainability while the grant is short-term?
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Sustainability has to be designed at month one, because a 12-month grant cannot fund a 12-month program and also fund the search for its replacement.
Revenue. Determine whether the health center can bill for diabetes self-management education and training. Medicare and most state Medicaid programs reimburse DSMT when the program meets the national standards and is recognized or accredited; the application takes months, so start it immediately and assign an owner. Screen patients for reimbursement eligibility and track the billable share so the chief financial officer sees a revenue line, not only a cost.
Workforce. Shift delivery from the 0.6 FTE educators to a task-shared model: CHWs deliver the CHW-appropriate content and follow-up, educators supervise and handle complex clinical teaching. Train the two new CHWs now, before the first cohort, not after. Build the curriculum into onboarding so MA turnover does not erase the program.
Institutional anchoring. Get the program written into the health center's diabetes registry workflow and quality dashboard, so it is part of how the center manages its patient panel rather than a grant project. Tie it to value-based payment measures the center is already reporting on.
Partnership. Formalize a memorandum of understanding with the county extension service or a pharmacy partner for ongoing group space and medication review, so the program does not depend on a single site.
Evaluation discipline. Report interim data at month six, not month twelve. A funder deciding on renewal in month ten needs improvement evidence before then. Frame the case in RE-AIM terms - reach, adoption, implementation, maintenance - because the foundation will ask whether the model can continue without them.