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rewrite to avoid ai detection. make it sound human. To ensure that all patients receive wraparound support for social determinants of health, the program will implement two additional strategies. First, nurses will complete social needs screenings during the initial intake appointment to identify barriers such as food insecurity, housing instability, or lack of transportation. Patients with identified needs will receive individualized referrals to local community resources, such as food banks, transportation services, or housing assistance programs, to help them manage external factors that can affect their ability to follow a diabetes care plan (Makhfudli et al., 2025). Second, the program will build partnerships with community organizations to host resource fairs and invite service providers to the clinic regularly. This approach makes support services more accessible, reduces stigma, and helps patients feel more comfortable seeking help. Together, these strategies will create a comprehensive, patient-centered approach to diabetes management that tackles medical and non-medical barriers to better health outcomes.

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