 We will recruit eligible subjects who have an upcoming primary care visit with their primary care provider. Subjects will first be mailed letters, signed by a member of their own primary care team in these clinics, patients are usually under the care of a team and not one physician or the Clinic Medical Director in the absence of a primary team member, requesting their participation in the study. Subjects can call a toll-free number to request not to be contacted or if they have any questions opt-out strategy similar to prior studies approved by Dukes IRB. The research assistant will contact the subject by telephone to explain the study, screen for eligibility, arrange an in-person meeting at the clinic to further describe the study, obtain informed consent and interview the subject. Enrollment will be scheduled at a time when individuals will already be coming to their clinic and all subsequent outcome assessment will be obtained from medical records e.g., blood pressure, Hb A1c, and LDL-C, BMI and secondary outcomes e.g., behaviors will be obtained over the telephone. 