INCLUSION CRITERIA Section A: Demographic Criteria 1. Patient was seen in your clinic or practice at least once in the past 24 months 2. English-speaking male or female 3. Age is 50 or older at medical record screening Section B: Risk Factors - Must have at least one of the following conditions 4. Uncontrolled diabetes (Hemoglobin A1c > or + 7.5) 5. Elevated LDL cholesterol > 110 for patients with PAD, CAD, stroke or diabetes or > 140 otherwise 6. Elevated blood pressure with: - Systolic BP >= 140 or Diastolic BP >=90 in persons with diabetes or chronic kidney disease OR - Systolic BP >= 150 in persons with uncomplicated hypertension Section C: Cardiovascular Conditions - total number of risk factors in Section B (above) plus number of conditions Section C (below) must be THREE OR MORE 7. History of coronary artery disease 8. Previous Heart Attack 9. History of Stroke 10. History of Transient Ischemic Attack 11. History of Atrial fibrillation 12. History of Peripheral Vascular Disease / claudication 13. History of carotid artery disease 14. Current smoker 15. Obesity with BMI > 30 EXCLUSION CRITERIA Section D: Exclusion Criteria - has NONE of the following: 16. Inability to give informed consent 17. Pregnant 18. Diagnosis of pulmonary hypertension (Note: secondary pulmonary hypertension is OK) 19. Cancer diagnosis with a life expectancy estimated less than 2 years 20. Residence in a nursing home or diagnosis of dementia 21. No telephone or a hearing impairment not allowing them to use a phone 22. Refusal to consider attempting to use the internet at home, community center, library, medical office or other source to access the PHRM 23. Patient has plans to move from the area or transfer care to a different clinic in the next 12 months 24. Omron blood pressure cuff cannot be used on patient's arm for any reason

Inclusion Criteria: - Must have at least one of the following conditions - Uncontrolled diabetes (Hemoglobin A1c > or + 7.5 - Elevated LDL cholesterol > 110 for patients with stroke or diabetes or > 140 otherwise - Elevated blood pressure with systolic pressure 140 or higher in persons who have diabetes or chronic kidney disease and 150 or higher otherwise. - Persons who have only one or two of the conditions listed above must also have had one or more of the following conditions, so that the total number of conditions is at least three: - Coronary Artery Disease - Previous Heart Attack - Stroke or Transient Ischemic Attack - Atrial fibrillation - Peripheral Vascular Disease - Smoker - Obesity Exclusion Criteria: -

The overall status was removed for UI Health Care-River Crossing.