The average A1C of 7.35 among program patients suggests that while some diabetes management efforts are working, many patients remain slightly above the recommended target (<7.0). Contributing factors may include inconsistent follow-up visits, medication non-adherence, limited access to healthy foods, and barriers such as transportation or cost.

Some patients may also struggle with low health literacy, making it harder to understand and manage their condition. Staffing shortages and limited time for one-on-one education may also reduce the program’s effectiveness. Social determinants of health—like stress, housing instability, and financial hardship—can further impact diabetes control.

To move the curve downward, the program may benefit from enhanced education, case management, home monitoring support, and stronger follow-up systems.