Social medicine approaches to community-integrated diabetes care: A narrative review of clinic-based triaging and closed-loop referral interventions

The global prevalence of type 2 diabetes mellitus (T2DM) has risen to more than 800 million people and is projected to exceed 1.3 billion by 2050, with racially and ethnically minoritized populations experiencing disproportionate morbidity, mortality, and barriers to prevention and management. Health-related social needs (HRSNs), including food and housing insecurity, transportation barriers, and low health literacy, shape these inequities and reflect long-standing structural forces. In response, many health systems have adopted standardized HRSN screening tools in primary care; however, screening alone is insufficient to address the complexity of patients' needs or the systemic inequities that produce them. This narrative review synthesizes 24 implementation studies examining real-world integration of HRSN screening in clinical settings. Five recurrent barriers emerged: absent or inconsistent triage processes, fragile relational infrastructure between clinical and community partners, weak or eroded closed-loop feedback mechanisms, misalignment between technology and workflow, and inadequate accountability for equity goals. These challenges contribute to fragmented systems that identify needs without ensuring follow-up or resolution. Findings indicate that effective integration requires an end-to-end approach that links screening, triage, referral, and feedback within equity-oriented models of care. Social medicine informed frameworks that strengthen relational trust, cross-sector coordination, and community partnership may support more durable and responsive systems for addressing HRSNs among patients with T2DM and other chronic conditions.