Participants Within each CU, AMPATH has initiated home-based testing and community-level screening of glucose and BP, with a plan to cover one-third of each CU's population every year. Adult individuals with elevated BP (SBP ≥ 140 or diastolic BP (DBP) ≥ 90) or elevated random blood glucose (≥ 8.1 mmol/L) will be assigned a unique AMPATH Medical Record System identification number and referred to the local rural health facility for further evaluation and confirmation of disease status. At the health facility, each individual will have a repeat BP and fasting glucose measured, and those who meet the designated cutoffs (repeat SBP ≥ 140 or DBP ≥ 90; fasting glucose ≥ 7 mmol/L) will be entered into the CDM Program.