Implementation pRogram to Improve Screening and Management for CKD in Diabetes (IRIS-CKD) (Program 2)

Inclusion Criteria:

* (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.).

Exclusion Criteria:

* (CKD Management)

  * Type 1 diabetes
  * Most recent eGFR \<20 ml/min/1.73 m2
  * Prior kidney transplant
  * Autosomal dominant polycystic kidney disease (ADPKD)
  * Active pregnancy or plans for conception within 1 year