Prevalensi penyakit DM meningkat seiring bertambahnya usia lansia sebagai kelompok yang rentan. Sehingga perlu pemantauan dan pengendalian faktor risiko mencegah terjadinya komplikasi. Karya Ilmiah Akhir ini menggunakan integrasi teori manajemen keperawatan, community as partner, family centre nursing, dan health belief model. Pengkajian pada 30 lansia dengan total sampling. Bentuk intervensi yang digunakan yaitu pembentukan kelompok swabantu dan pendukung, promosi kesehatan, konseling, coaching dan terapi modalitas, dengan media dokumentasi BP2DM. Hasil pre-post intervensi CERDIKK selama 9 bulan menggunakan uji paired t-test dengan nilai p:0.000 memberikan makna ada pengaruh perilaku lansia dalam pengendalian DM, meningkat perilaku kelompok pendukung dan terjadi penurunan kadar gula darah lansia DM 73 mg/dl. Program CERDIKK dinyatakan efektif dalam pemantauan dan pengendalian DM lansia. Diharapkan program ini melibatkan kader dan perawat komunitas secara aktif.

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The prevalence of DM increased as ones getting older and are categorized as a vulnerable group. There is a need to monitor and control the risk factors of DM to prevent complication. This scientific paper used the integration of theory management nursing, community as partners, family centered nursing and health belief model. A total sampling of 30 elderlies were involved for the assesment. The intervention used were the self help group and support group, health promotion, counseling, coaching and therapeutic modalities, using media documentation BP2DM. The result of pre-post intervention CERDIKK for 9 months using paired t-test with p:0.000 showed there was significant influence of the the elderly behavior in controlling DM. The increase of support group behavior and the decline in blood sugar levels 73 mg/dl were also evident. CERDIKK program is effective to use in the monitoring and controlling of DM elderlies. It is recommended to actively involve cadres and community nurses.