MATCH2 Trained CHW Interventionists will work closely with patients to deliver a participant-centered intervention derived from two pragmatic evidence-based frameworks for behavioral change [Motivational Interviewing (MI) and Kate Lorig's Chronic Disease Self-Management approach]. 24 total in-person visits will be conducted; six primary topics will be covered multiple times over an 18-month period. No more than two topics will be addressed at any visit. The sequence in which topics are delivered is determined by participant need, preference, and interest. The six primary topics are: