• (CKD Management)

‣ Adults with type 2 diabetes (T2D)

⁃ Receiving primary care within the healthcare system, visit within 24 months (any PCP provider, including APP)

⁃ Evidence of CKD based on laboratory testing within the past 2 years (must be confirmed during screening if not checked within 3 months of enrollment):

• UACR \>300 mg/g or

∙ eGFR \<45 ml/min/1.73 m2 or

∙ UACR ≥30 mg/g with eGFR \<60 ml/min/1.73 m2

⁃ Receiving \<100% GDMT at baseline. For patients with UACR \<30 mg/g, GDMT includes sodium-glucose cotransporter-2 inhibitors (SGLT2i) therapy. For all other eligible patients, GDMT includes ACEi/ARB, SGLT2i, and Finerenone, unless contraindications for any of these therapies exist (e.g., hyperkalemia, diabetic ketoacidosis, etc.).