Achieving Chronic Care equiTy by leVeraging the Telehealth Ecosystem

Inclusion Criteria:

* ≥ 18 years of age
* English or Spanish-Speaking
* Have uncontrolled diabetes defined as a listed diagnosis of diabetes with a recorded A1C ≥ 8.0% in the past two years or have uncontrolled HTN defined as a listed diagnosis of HTN and last recorded documented SBP \>140 mmHg
* At least 2 visits at a participating SFHN primary care site in the last 24 months

Exclusion Criteria:

* Higher than average digital literacy, defined as an Digital Healthcare Literacy Scale (DHLS) score greater than 10, as determined prior to the baseline study visit; these patients may not benefit from a digital coaching intervention.
* Presence of co-morbid conditions that would make it inappropriate to focus on telehealth chronic disease management. Conditions may include: end-stage or terminal condition with limited life expectancy and severe mental illness.
* Lack of any working phone number
* Visual or hearing impairment that precludes use of telehealth for chronic disease management
* Cognitive impairment defined by the inability to restate study goals during the consent process
* Pregnant