At each visit, CHWs will help participants develop a self-management Action Plan around one of the six topics, and support problem solving behaviors to address barriers to completing the Action Plan. Behavioral self-management skills will be taught by the CHW and practiced with the participant at each visit. CHWs will monitor the clinic attendance of participants and will advise and assist participants with making appointments with their primary care providers at least once every 4 months. CHWs will also play an active role in communicating the progress of their participants to the primary care providers using the clinic Electronic Medical Record.