Diabetes Remote Intervention to improVe Use of Evidence-based Medications

1. Aged 27 - 79 years at the time of agreeing to participate in the program

2. Presence of type 2 diabetes (treated with metformin unless intolerant, may also be treated with DPP4i, sulfonylurea, pioglitazone, and/or basal insulin)

3. HbA1c 6.5-8.9%; AND

4. At elevated cardiovascular and/or renal risk defined as any diagnosed ASCVD, estimated ASCVD risk >10%, congestive heart failure, non-alcoholic fatty liver disease, estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2, albuminuria above 300mg/g; and those aged 60 years or older with at least two of: active tobacco use, dyslipidemia (LDL-c above 160 mg/dL or 4.1 mmol/L, non-HDL-C above 190 mg/dL or 4.9 mmol/L, triglycerides above 175 mg/dL,) hypertension (2 systolic blood pressure values above 130 mmHg and/or 2 diastolic blood pressure values above 90 mmHg within 12 months,) or BMI above 30

5. Has seen a primary care provider within the Mass General Brigham network within the last year

1. Type 1 diabetes

2. Currently or previously prescribed an SGLT2i or GLP1-RA

3. Taking any short-acting insulin

4. History of diabetic ketoacidosis

5. History of hypoglycemia requiring hospitalization

6. Frequent (more than two times in 1 week) episodes of symptomatic hypoglycemia with blood glucose <70 mg/dL

7. eGFR below 15 ml/min/m2

8. Mental incapacity, unwillingness, or language barriers precluding adequate understanding or cooperation, OR

9. Life expectancy less than 1 year or utilizing palliative care