Given these attributes, the CHWs will facilitate the participants in the study to better understand their health conditions, make effective decisions about them, and cope with challenges to optimizing their holistic health, including navigating the often-complex healthcare system, while helping them strategize to manage the logistics of caring for self in the context of complicated lives. Community Health Workers (CHWs) will be members of the TN CEAL research team and work as frontline personnel to screen, enroll, support, and track progress of participants in the study who have multiple chronic diseases and live in areas designated as medically underserved or socially vulnerable.