Integrated Population Program for Diabetic Kidney Disease

Potentially eligible patients will be identified using the existing SEDI (Southeastern Diabetes Initiative) data warehouse that pulls electronic health record data quarterly from ten different source systems in the four counties. * Adults (age ≥18 and 75 years); * Diagnosis of type 2 diabetes (ICD-9 codes 250.x0, 250.x2); * Have at least 2 serum creatinine values available in the 3 prior years, separated by at least 3 months; * Preserved kidney function (based upon the last year's eGFR average of between 45-90 ml/min/1.73m2, estimated by calculating an eGFR using the 4-variable Modification of Diet in Renal Disease study equation); * Evidence of diabetic nephropathy (Either: 1. presence of macroalbuminuria; 2. history of microalbuminuria prior to ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker (ARB) therapy; 3. previous documentation of diabetic retinopathy or laser therapy; 4. if only microalbuminuria and no #3, then urinalysis without hematuria, and no other renal etiologies \[i.e., glomerulonephritis, polycystic kidney disease, membranous nephropathy, renal artery stenosis\]) * Uncontrolled HTN (1y mean clinic SBP≥140 and/or DBP≥90). Exclusion Criteria: Patients who meet any one of the exclusion criteria will be excluded: * No access to telephone * Not proficient in English * Nursing home/long-term care facility resident or receiving home health care * Impaired hearing/ speech/ vision * Participating in another trial (pharmaceutical or behavioral) * Planning to leave the area in the next 3 years * Pancreatic insufficiency or diabetes secondary to pancreatitis * Alcohol abuse (\>14 alcoholic beverages/ wk) * Diagnosis of non-diabetic kidney disease * Active malignancy (other than non-melanomatous skin cancer) * Diagnosis of life-threatening disease with death probable within 4 years.