 METHODS We will take advantage of the naturally occurring variation in the implementation of PAE activities in 16 practices of two ACOs treating patients with diabetes and cardiovascular disease CVD. A random sample of chronically-ill patients from each of the two ACOs will be sampled and will complete a patient-reported outcome instrument that includes select Patient-Reported Outcomes PROMIS measures and patient experience measures in early and late stages of the project. They will also complete the patient activation measure PAM. We will examine changes over time in the outcome variables noted above. We will also survey ACO practice stakeholders regarding organizational culture, leadership, team effectiveness, and relational coordination using previously validated instruments supplemented by site visits. Multilevel analyses examine PAE effects and practice-level heterogeneity within ACOs, controlling for patient characteristics. 