AimsThis study examined whether the Chronic Care Model can be successfully applied to improve health outcome measures for uninsured, undocumented immigrants with diabetes at a free, non-federally funded community clinic.MethodsData were collected from 128 uninsured, undocumented immigrants enrolled inPrograma de diabetes, a comprehensive diabetes program at People’s Health Clinic based on the six core elements of the Chronic Care Model. All study participants self-identified by the Hispanic ethnicity. A longitudinal study design was used to compare baseline diabetic health measures with outcome data after patient program participation over a 12-month enrollment period. Linear mixed effect model was used to determine the patient specific change in HbA1C across time, controlling for gender, age, food insecurity, income level, diabetes type, and literacy. In addition, McNemar tests were conducted to compare the coverage of eye exams and statin use before and after program enrollment.ResultsAfter program enrollment, individual specific change in HbA1C was expected to be − 0.201 [95% CI 0.244, − 0.158] % per month after controlling for baseline covariates. There were statistically significant improvements in both eye exam coverage (p< 0.01) and statin use (p< 0.01).ConclusionsThe Chronic Care Model can be successfully applied to improve health outcome measures at a free, non-federally funded community clinic among uninsured, undocumented immigrants, who identify by the Hispanic ethnicity and have the diagnosis of diabetes. Barriers to care including food insecurity, federal poverty level and illiteracy do not preclude glycemic control.