Diabetes - The Arizona Department of Health Services (ADHS) is located within Maricopa County at 150 N 18th Avenue, Phoenix AZ and is the state Public Health Agency. ADHS mission is to promote, protect, and improve the health and wellness of individuals and communities in Arizona; which includes a vision of health and wellness for all Arizonans. ADHS envisions a comprehensive, data-driven approach to decreasing A1C values for Arizonans with prediabetes. This will be accomplished by developing and supporting linkages and electronic infrastructure that will increase availability and access to proven and effective community-based, accredited chronic disease prevention and management programming. Arizona has high diabetes and prediabetes rates, especially among the Tribal, African-American, and Hispanic/Latino communities living in rural and border areas. Close to 2 million Arizonans have prediabetes, which is approximately 1 in 3 adults—and about 600,000 adults have diabetes. During the grant period, ADHS will leverage strong community partnerships for state-wide reach and focus efforts in sustaining and promoting evidence-based practices and interventions. Recent legislative actions impacting diabetes management and existing collaborative efforts with the state’s leading diabetes organizations are advantageous to our goals. Through collaborative agreements, ADHS will create capacity to increase community clinical linkages that connect people to prediabetes and diabetes prevention and management services. This includes implementing state-wide, multi-directional referrals to complementary programs and resources that address social determinants of health (SDOH). ADHS will coordinate a collaborative and community-driven approach to achieve outcomes for each strategy and activity selected from Component A. The strategies and activities align with the Healthy People 2030 objectives and will allow for the sustainability of the diabetes program. ADHS will manage collaborative agreements to produce the following outcomes during the five-year period: decrease the proportion of people with diabetes with A1C >9%; increase the number of organizations implementing evidence-based community behavioral change programs; increase participation in evidence-based community behavioral change programs; increase the # of program participants retention (total # and # from priority populations) served by CDC-recognized National DPP delivery organizations who reduce their risk for type 2 diabetes. ADHS will also work to produce increased multi-directional communication between clinical and community resources by tracking the increased # of patients screened and referred to community resources (i.e., health/mental health resources). ADHS has selected six strategies to achieve the outcomes listed above: Strategy 1, Strategy 5, Strategy 7, Strategy 9, Strategy 10, and Strategy 12. ADHS seeks to sustain accredited DSME and CDC-recognized National Diabetes Prevention Programs by creating an Umbrella Hub Arrangement (UHA) and a formalized Arizona Diabetes Referral Network. Establishing these systems by creating the referral and billing infrastructure will serve to increase enrollment in accredited and recognized programming and supplemental services. The created UHA and Referral network will help health care organizations to augment their diabetes and prediabetes program in their patient care process.