Inclusion Criteria:  Eligible participants will be 18-89 years old of any gender At least 1 chronic medical condition including obesity, diabetes, hypertension, chronic kidney disease, coronary artery disease, chronic lung disease, active smoker, and stroke. Participants with Medicare and/or Medicaid insurance Home address falls within a West Philadelphia zip code (19104, 19131, 19139, 19143, 19151)  Exclusion Criteria:  Adults 90 and older Patients who are unable to provide consent due to mental disability or illness Patients unable to participate in a verbal interview due to a physical or mental health condition will also be excluded