Embedded Primary Care MultiDisciplinary Diabetes Clinic

Once a week, a Primary Care clinic half-day will be dedicated to multi-disciplinary, team-based DM care. The inter-professional team will include an Internal Medicine attending physician, an Internal Medicine resident, a DM educator, a nurse trained in professional CGM, a behavioral health provider, and a social worker to assist in finding resources for housing, food, and patient assistance programs.

Researchers will use a 2:1 ratio of control to intervention patients. Using the CDW, researchers will identify a control population \[patients who receive routine care (i.e., referral to subspecialty care)\], who will be a propensity-matched cohort of individuals with similar age, gender, race/ethnicity, zip codes, insurance type, visit dates, and co-morbidities (Charlson Comorbidity Index) as the intervention group.