Southeastern Diabetes Initiative Clinical Intervention

Clinical care will be delivered by a multidisciplinary team including (but not limited to)
an physician, nurse practitioner, dietician, pharmacist, licensed clinical social worker
(LCSW), case manager, health educator and a community health worker. Care will be delivered
in community settings including home visits and community based clinics. With the exception
of specific surveys (listed in the Study Intervention section) all data are being collected
for the purpose of delivery of standard preventive care and clinical care. The population
group will include patients diagnosed with Type 2 Diabetes Mellitus in four Southern United
States counties, meeting certain inclusion criteria, and deemed "high risk" as determined by
a set of standard criteria or a risk algorithm run on secondary data.

The investigators plan to characterize patients diagnosed or at risk for diabetes mellitus,
and allow more detailed knowledge of their health than is provided by standard public health
data. The investigators will use descriptive, parametric and non-parametric statistics to
describe baseline characteristics (demographics and clinical measures of disease severity)
of the sample and will compare responders and dropouts on independent and dependent
variables, report any significant differences, and include this in the interpretation of
results.

Inclusion Criteria:

- Adults >=18yrs

- Diagnosis of Type 2 diabetes

- Reside in Durham County, NC, Cabarrus County, NC, Quitman County, MS or Mingo County,
WV or the neighboring areas and receive the majority of their healthcare in the four
listed counties.

- Have capacity to give consent (or have a surrogate legally authorized representative
or caregiver provide consent on their behalf).

- Defined as high risk by the risk algorithm or their primary care clinician.

- Referral from the primary care clinician or patient's medical home if one has been
designated.

Exclusion Criteria:

- Lack capacity to make decisions and do not have a surrogate with authority to make
health care decisions.

- Have a terminal illness with a life expectancy of 6 months or less

- Diagnosis of Type 1 diabetes or gestational diabetes

- Currently pregnant (confirmed via self-report and/or medical record)