 1 To collect information on the PAE activities in 16 practices of two ACOs at baseline and over three years - including initiatives focused on disease prevention and health promotion, care team-patient communication, shared decision-making, self-management support, advanced serious illness care, and patient involvement in the care redesign experience; 2 to assess the differences on patient-reported outcomes of care, patient experiences, and selected clinical measures between patients exposed to highly developed PAE initiatives versus those receiving care from practices with minimal PAE activities; and 3 examine practice-level variation in PAE implementation processes including culture, leadership, teamwork, and relational coordination. 