Advancing Care and Equity for Diabetes (ACED) Prevention and Management - The Fund for Public Health in New York, Inc (FPHNY) is applying for Component B (Strategies1, 3, 4, 5, 10, 13) of this opportunity. The proposed project will focus on 22 NYC neighborhoods located in the “high risk” counties - the Bronx, Queens, and Kings (Brooklyn) county. The burden and risk of diabetes is linked to the conditions in which people live, work, play and pray. These circumstances are shaped by racial, social, and economic injustices that drive health inequities. In New York City (NYC), diabetes has risen from the tenth leading cause of death in 1990 to the third in 2019. The three “high needs” counties identified by the Center of Disease Control and Prevention (CDC) – Bronx, Kings, and Queens – are disproportionately impacted by diabetes with overall diabetes prevalence of 15.8%, 12.4%, and 12.8%, respectively. Within these counties, the burden and risk of diabetes as well as the social determinants of health (SDOH) that drive inequities are more pronounced in specific neighborhoods. Advancing Care and Equity for Diabetes Prevention and Management, referred to as “ACED”, is a NYC Department of Health and Mental Hygiene (DOHMH) initiative to decrease risk for type 2 diabetes through improved screening for diabetes risk and increase access and completion of community change programs for those at risk; decrease the proportion of people with diabetes that have an A1C>9% and increase early detection of diabetes-related complications through improved self-care practices and quality of care; and advance health equity by addressing the SDOH that impacts priority populations. ACED can potentially reach nearly 802,000 adults, of whom over 87,000 have diabetes, living in priority neighborhoods Through a collective impact approach and building on achievements, partnerships, and lessons learned from previous CDC grants, DP14-1422-PPHF14 and CFDA:93.435 DP18-1817, DOHMH will partner with community and clinical organizations to expand access to sustainable services that prevent diabetes, foster self-management among people with or at risk for diabetes, and implement evidence-based interventions to improve the management of diabetes. ACED can potentially reach nearly 802,000 adults, of whom over 87,000 have diabetes, living in priority neighborhoods. The proportion of people with diabetes that have an A1C>9% will decrease from 18.0% to 11.6%, a decrease of 36% over the five years. Further, 743 more completers served by CDC-recognized National Diabetes Prevention Program will reduce their risk for type 2 diabetes. Combined, there will be 68 organizations, including 41 new partner organizations, implementing DSMES, diabetes support, and National DPP programs/services that are tailored for priority populations, resulting in increased access for 10,400 adults in priority neighborhoods to DSMES, diabetes support, and National DPP programs/services tailored for priority populations. Further, 150 more clinical organizations will screen for SDOH increasing access to SDOH screenings in clinical organizations for 401,553 adults in priority neighborhoods, over 40,000 of which have diabetes. Additionally, 182 more community and clinical resources serving priority populations will have gained access to and actively used multidirectional e-referral systems.