TAU participants will receive standard care from the UMass Memorial Healthcare (UMMH) hospitalist team as appropriate. Participants will receive a printed list of community resources. No study-related patient navigation support will be provided.

In 2024, Centers for Medicare and Medicaid Services mandated social determinants of health (SDOH) screening for inpatients. UMMH will use a checklist social needs screener. It will be up to the hospitalist teams to act on SDOH screening results. The UMMH hospitalist teams may consult endocrinology and/or inpatient social services to provide support and consultation for all patients regardless of study participation or group assignment. If medically appropriate, the endocrinology service may manage medications and provide referrals for continued treatment post discharge. All services that are normally provided by hospital care teams will remain available.

Change in patient-reported adherence to diabetes regimen from baseline to follow up assessed by administering the Changes in the Summary of Diabetes Self-Care Activities Assessment (SDSCA) & Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) for Medication Adherence.

SDSCA - Scores are calculated for each of the five regimen areas assessed: Diet, Exercise, Blood-Glucose Testing, Foot Care, and Smoking Status.

REDD-CAT Medication Adherence scale is measured using T-scores. Scores greater that 1 standard deviation of 10.0 away from the mean of 50.0 represent a greater or lesser degree of adherence, depending on direction. Higher scores are indicative of a positive outcome (more adherence).

Change in experience of Illness Burden. Illness burden scale generates a T-score, ranging from 20 to 80. The average score is 50 with a standard deviation of 10. T-scores that are 1 or more standard deviations above average are indicative of a poorer outcome (indicate more illness burden).

Change in Substance Use will be assessed using a validated measure from the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS scores have an average of 50 and standard deviation (SD) of 10 in a referent population.

PROMIS Substance Use - Resulting scores are on a T-score metric ranging from 20 to 80. Scores that are 1 or more standard deviations above average are indicative of poor, self-reported health (greater severity of substance use).

Change in Alcohol Use will be assessed using a validated measure from the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS scores have an average of 50 and standard deviation (SD) of 10 in a referent population.

PROMIS Alcohol Use: Resulting scores are on a T-score metric ranging from 20 to 80. Higher scores are indicative of poor self-reported health (more alcohol consumption, cravings, or difficulty controlling drinking).

Type 2 Diabetes Stigma Assessment Scale or DSAS-2 is a 19-item measure with three sub-scales: Treated Differently, Blame and Judgement, Self-Stigma. A total scale score can also be calculated. Items are scored 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate worse outcomes (more perceived diabetes stigma).

Changes in 8-item custom short form from the Economic Quality of Life item bank. Items are related to finances and affordability of living expenses and range from 1 (Never) to 5 (Always). Resulting scores are on a T-score metric, ranging from 20 to 80. Higher scores indicate better economic quality of life.

Changes in depressive symptom burden are assessed using a measure from the Quality of Life in Neurological Disorders (NeuroQOL) measurement system.

Neuro-QoL Depression - Resulting scores are on a T-score metric, ranging from 20 to 80. Higher scores indicate poorer self-reported health (a greater presence of depressive symptoms).

Changes in anxiety symptom burden are assessed using a measure from the Quality of Life in Neurological Disorders (NeuroQOL) measurement system.

Neuro-QoL Anxiety - Resulting scores are on a T-score metric, ranging from 20 to 80. Higher scores indicate poorer self-reported health (a greater presence of anxiety symptoms).

Changes in emotional support scores assessed using measures from the Patient-Reported Outcomes Measurement Information System (PROMIS).

Resulting scores are on a T-score metric, ranging from 20 to 80. Higher scores indicate worse outcome (a greater degree of social isolation).

Changes in Health Seeking Behavior scale, which includes 21 items including subscales related to Primary Care Provider, General, Family/Personal Friends, and Internet. Resulting scores are on a T metric, ranging from 20 to 80. Higher scores indicate a positive outcome (more health-seeking behavior).

Medication Adherence scores assessed by administering the Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) for Medication Adherence scale.

This is measured using T-scores. Scores greater that 1 standard deviation of 10.0 away from the mean of 50.0 reflect a greater or lesser degree of adherence, depending on direction. Higher scores are indicative of a positive outcome (more adherence).

Change in Perceived Competence in Diabetes Scale (PCDS) score - items are rated on a scale 1-7. Higher total scores indicate better self-reported health (a greater perceived ability to manage diabetes).

Change in Diabetes Self-Efficacy Scale (DSES) score - items are rated on a scale of 0-10 and summed for a total score. Higher total scores indicate better self-reported health (self-efficacy in managing diabetes).

Changes in Brief Resilient Coping Scale scores. Items are rated 1 ("does not describe me at all") to 5 ("describes me very well") and summed for a total score. Higher scores indicate better self-reported health (higher coping resiliency).

Change in Diabetes Knowledge and diabetes self-care will be assessed using the 23-item Revised Diabetes Knowledge Test (DKT2). DTK2 contains multiple choice questions to assess knowledge, and each question contains 4 responses for the respondent to choose from. Proportion of correct answers over total questions determine scoring.

Change in Housing Insecurity scores, which is a 22-item assessment to evaluate affordability, safety, and home features. Resulting scores use a T-score metric, ranging from 20 to 80. Lower scores indicate poorer outcomes (more significant concerns with housing stability).

Absolute change in total number of SDOH domains identified with an unmet need (i.e., food insecurity, housing insecurity, etc.) as reported on Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) screening tool.

Change in HbA1c values recorded from point-of-care tests or in the electronic health record at visits.

The Diabetes Distress Scale is a 17-item self-report instrument. Each item is rated on a 6-point scale from (1) "not a problem" to (6) "a very significant problem." The scale yields an overall distress score based on the average responses on the 1-6 scale for all 17 items. The scale also yields a score for each of 4 subscales based on the average response on the 1-6 scale on all of the items in that scale.

An average score of < 2.0 = reflects little or no distress, an average score between 2.0 and 2.9 = reflects moderate distress, and an average score > 3.0 = reflects high distress.

Time-to-hospital reutilization (defined as any type of hospital service use, e.g., emergency department, observation, or hospital readmissions), at 30-days post-hospital discharge. Source of the data are UMMH electronic health records and participant self-report.