ASCEND: ApproacheS to CHC ImplEmeNtation of SDH Data Collection and Action

This work will test a set of strategies for helping community health centers (CHCs) routinely identify and take action on the SDH-related needs of patients with / at risk for DM using a stakeholder-driven process to develop EHR-based SDH data collection / summary tools for CHCs.

Inclusion Criteria: * Any persons who are at risk for type 2 diabetes * May include some subjects with mental health conditions of various types; however, it is important to systematically address high DM /obesity risk in this population, because such patients may be at risk for elevated high DM /obesity risk and have often been excluded or underrepresented in previous research studies. * Decisionally/cognitively impaired * Economically/educationally disadvantaged * Non-English Speakers * Elderly Exclusion Criteria: * Neonates of uncertain viability or nonviable neonates (up to 28 days post birth) * Prisoners Note: The investigators are not enrolling patients for this clinic-randomized study, but rather studying the uptake and impact of a set of EHR-based clinical decision support tools into regular care at the participating clinics. In this clinic-randomized trial, the intervention / randomization are clinic level. The intervention targets clinic processes that are part of the regular care patients receive, and will not require special visits.