Inclusion Criteria- 65 years of age and older;
- One of the four vascular conditions: Stroke and TIA, Hypertension, Cardiovascular disease and Heart failure
- Newly referred (following initiation of the study) for home care services and living in the community, including supportive housing, retirement homes, and lodging homes and excluding long-term care;
- At least 1 comorbid conditions;
- Able to speak English or have access to a translator;
- Not planning to move away from the CCAC catchment area in the next 6 months;
- Be mentally competent to provide informed consent, either independently or by a substitute decision maker.