HLTH 4343 Module 4 Service Model Comparison Example

Promotoras or Group Visits? Comparing Two Diabetes Service Models for Spanish-Speaking Adults at a Border Health Center Network Against Evidence, Fit and Cost

Student Name

American College of Education

HLTH4343: Health and Wellness Across Populations

Module 4 Assignment

Instructor Name

October 26, 2026

The Choice Facing the Network

The composite four-clinic health center network in Imperial County, California, that I have followed in this course has funding for one new diabetes program next year. The earlier modules established the need: diabetes affects an estimated 14.6% of adults in the county, compared with 9.4% in neighboring San Diego County (Centers for Disease Control and Prevention [CDC], 2025), and the network's patients face barriers of language, cost, transportation, heat and work hours. The network's leaders have narrowed the options to two established service models. The first uses community health workers, known locally as promotoras, who come from the community they serve. The second uses shared medical appointments, often called group visits, in which several patients with diabetes meet together with a clinician and educator for a longer visit.

This paper compares the two models on four grounds: the evidence of effect on blood glucose, fit with this population, what each requires of the network, and cost. It then recommends a program design.

Model One: Community Health Workers

Community health workers are trusted members of a community who provide education, support, navigation and advocacy, usually working alongside clinical teams. In diabetes care, they typically make home visits or phone calls, teach self-management skills, help patients get to appointments and obtain medications, and connect them with food, housing and benefits programs. The model is especially well suited to populations that face language and cultural barriers, since workers share the patients' language and experience.

The evidence for effect on glucose control is positive but modest. Palmas et al. (2015) reviewed randomized trials comparing community health worker interventions with usual care and meta-analyzed nine trials with at least twelve months of follow-up. They found a modest reduction in hemoglobin A1c, with a standardized mean difference of 0.21, and a larger reduction in studies whose participants started with higher A1c levels. The authors cautioned that the number of trials was small and that publication bias could not be ruled out. The finding about baseline A1c matters here: the network's data show that a large share of its patients are diagnosed late with high A1c levels, the group in which community health workers appear to help most.

Model Two: Shared Medical Appointments

In a shared medical appointment, a group of eight to twelve patients with the same condition meets with a clinician, and often a nurse, dietitian or pharmacist, for ninety minutes or more. Each patient receives individual attention to medications and results, and the group discusses self-management together, learning from one another's experience. The format gives patients more time with the care team than a standard visit and can improve clinic capacity.

Edelman et al. (2015) systematically reviewed 17 unique studies comparing shared medical appointments with usual care for patients with diabetes. Group visits improved hemoglobin A1c by 0.55 percentage points and systolic blood pressure by 5.2 mmHg, but did not significantly improve LDL cholesterol. The A1c results varied considerably across studies, which the authors attributed to differences in the components of the programs, and they found too little evidence to draw conclusions about patient experience, use of services or costs. The model's effect on A1c appears larger in absolute terms than that of community health workers, though the two reviews measured effects differently and cannot be compared directly.

Fit With This Population

Evidence from trials tells us what a model can achieve under study conditions; fit tells us whether it will work here. Community health workers fit the population's barriers closely. They can visit patients at home or at work sites, which addresses transportation and work hours; they speak Spanish and understand the local food and family context; and they can help with the coverage enrollment and benefits that the earlier analysis identified as critical. Their weakness is clinical: they cannot adjust medications, so their effect depends on a strong link to clinicians.

Group visits fit some needs well and others poorly. They offer Spanish-language groups, extended time and the peer support that many isolated patients lack, which responds to the county's high reported loneliness. But they require patients to come to the clinic at a set time for ninety minutes, which is difficult for agricultural workers during harvest and for anyone without a ride. A model that works beautifully for the patients who can attend does nothing for the patients who cannot get there.

Requirements and Cost

The two models make different demands on the network. A community health worker program would require hiring and training four workers, one for each clinic, at about $52,000 each in salary and benefits, plus training, mileage, phones and supervision by a nurse, for a total of about $265,000 a year. Workers can be hired locally and trained within three months. Group visits would require clinician time: two ninety-minute sessions per clinic each month, led by a physician or nurse practitioner with a registered nurse and a dietitian, plus a room large enough for a group. Because group visits can be billed as medical visits for each attending patient, a substantial part of their cost may be recovered through billing, whereas community health worker services are only partly reimbursed in California's Medi-Cal program and would rely more on grant funding. The network's main constraint is clinician time, which is already stretched.

Recommendation: A Hybrid Built Around Promotoras

Neither model alone fits the network's population. I recommend a hybrid built around community health workers, with group visits as one of the services they connect patients to. Four promotoras would each carry a caseload of about 60 patients with diabetes, prioritizing those with A1c above 9%, the group in which the evidence suggests community health workers help most. They would visit patients at home or at work, help with coverage and benefits, teach self-management, and link patients to a monthly Spanish-language group visit at each clinic, scheduled in the evening outside harvest peaks. The promotoras would attend the group visits, which strengthens the link between community support and clinical care that each model lacks alone.

The hybrid addresses the weaknesses of each model: the promotoras reach patients who cannot come to the clinic, and the group visits provide the medication adjustment and extended clinical time that the promotoras cannot. It also fits within the network's clinician capacity, since group visits would run monthly rather than twice monthly.

How the Choice Will Be Judged

The hybrid will be evaluated after one year with four measures: the change in A1c among enrolled patients, reported separately for those who attended group visits and those who did not; the share of enrolled patients who completed coverage enrollment or benefits referrals; attendance at group visits by season; and patient-reported support, using a short Spanish-language survey. Because the network is combining two models, it cannot tell from its own data which part produced any improvement, and it should not claim more than the evaluation can show. The results will instead guide the next decision, whether to expand promotora caseloads, add group visit sessions or change the mix.

References

Centers for Disease Control and Prevention. (2025). PLACES: Local data for better health, county data 2025 release [Data set]. https://data.cdc.gov/

Edelman, D., Gierisch, J. M., McDuffie, J. R., Oddone, E., & Williams, J. W., Jr. (2015). Shared medical appointments for patients with diabetes mellitus: A systematic review. Journal of General Internal Medicine, 30(1), 99-106. https://doi.org/10.1007/s11606-014-2978-7

Palmas, W., March, D., Darakjy, S., Findley, S. E., Teresi, J., Carrasquillo, O., & Luchsinger, J. A. (2015). Community health worker interventions to improve glycemic control in people with diabetes: A systematic review and meta-analysis. Journal of General Internal Medicine, 30(7), 1004-1012. https://doi.org/10.1007/s11606-015-3247-0