Inclusion Criteria:

• * Age \>= 18 years and \<=75 years (since children have different incidence, management, and outcomes of Type 2 diabetes (T2D) compared to adults and older adults aged more than 75 years may have had their hemoglobin A1C (HbA1c) goals adjusted to higher thresholds)
• * HbA1c reading ≥ 8% recorded during 6 months prior to or up to 9 days after the encounter at the participating practices
• * Uncontrolled type 2 diabetes (ICD-10-CM code E11.XX) recorded in the EHR in the year prior to up to 1 week after the uncontrolled HbA1c reading

Exclusion Criteria:

• * Patients with gestational or type 1 diabetes
• * Those enrolled in any other chronic disease management programs delivered by non-physician healthcare professionals
• * Those receiving T2D care from an endocrinologist
• * Those receiving long term, hospice, or palliative care services
• * Those with serious mental illnesses (schizophrenia and other psychotic disorders, major depressive disorders, bipolar disorders, and borderline personality disorder)
• * Those with malignant cancer
• * Those with cognitive impairment