2025 Program Analysis

Our DSMES program is the only one in the region reimbursable by Medicare, Medicaid, and private insurance. Performance is shaped by regulatory requirements:

• Staffing: National accreditation requires initial assessments be conducted by an RN or RD. Capacity is strictly limited by the availability of these specific licensed roles.

• Referral Barriers: Insurance-mandated referrals (signed by an MD, PA, or NP) are frequently returned incomplete or unsigned from clinics, stalling enrollment.

• Missed Appointments: High "no-show" rates and the coordination required for Spanish-language interpreters add significant complexity to scheduling and follow-up.

• Data Lag: Participants have one year to complete the curriculum, often spanning two calendar years. If not finished within that window, a new clinical referral is required, creating a barrier to re-entry.

• Engagement: While free community events and Support Groups see high engagement, our formal clinical programming (DSMES) requires more targeted marketing.

In 2025, our program celebrated 19 official completions, representing a dedicated group of residents and county employees who successfully navigated the mandatory 10-hour curriculum. These success stories prove that our education is highly effective, yet the low completion rate highlights a significant barriers to care for most participants. Major barriers include scheduling,  transportation gaps and conflicting work hours. Additionally, the strict one-year completion deadline often cause motivated individuals to lose their progress.

2020-2021

In order to complete the DSME Program, a participant must have an initial visit, complete 4 classes and the 3 month follow-up.  The number of initial appointments impacted the ability to have 3 month classes, as an educator left during 2020 and another one left during 2021.  In addition, Covid impacted the ability to have group education classes, so many classes prior to the 3 month follow-up were done individually, which allowed less time for 3 month up classes.

Another factor that may have contributed to the decline in 2020-2021 was that one of the referring physicians left in 2021.  He was no longer there to hold his patients accountable for program completion. 

It is important to note that in some cases, the patients who start in one calendar year complete the program in the subsequent year. 

The PCHD Diabetes Team: Managing outreach, scheduling, and patient reminders.

• Referring Providers: Our clinical bridge to the community, ensuring patient accountability.

• Individual Participants: The core of the program, driving our peer-led success.

National & Regional Partners

• National: American Diabetes Association (ADA).

• Clinical: ECU Health, James D. Bernstein Center, Kinston Community Health, and our network of regional specialty clinics.

• Community: Make Pitt Fitt Garden, Employee Wellness, and Nutrition Programs.

What Works: 2025 Success Factors

• Strategic Provider Alignment: Our success has been driven by referring providers who do more than sign paperwork; they actively follow up with their patients and hold them accountable for program participation and health outcomes.

• Optimized Group Learning: By prioritizing group classes over individual sessions, we have successfully increased our reach, allowing more participants to engage, share experiences, and learn simultaneously.

• Staffing and Capacity Management: Maintaining adequate, specialized staff has been essential to providing a consistent schedule of both initial visits and comprehensive classes.

• Proactive Engagement: The PCHD Diabetes Team’s commitment to consistent reminder calls has been a critical factor in reducing barriers to attendance and maintaining patient momentum.

• Perform manual reminder calls to all participants 48 hours before each scheduled class or session to reduce no-shows.
• Send the Constant Contact newsletter monthly to provide consistent reminders and updates for the Support Group.
• Schedule all classes at the initial appt
• Begin Make Pitt Fitt Community Garden trips to keep participation high outside of the clinic.