Project 2: ACHIEVE- HF

Inclusion: In order to be eligible to participate in this study, an individual must meet all of the following criteria: 1. Detroit-area resident (defined as those who attended a Detroit-area community event) 2. ≥18 years of age 3. At least one of the following: A) Screening systolic BP ≥ 140 and/or diastolic BP ≥ 90 mm Hg OR B) Screening BP 130-139 mm Hg plus ≥1 additional HF risk factors: i. Diabetes (HbA1c ≥ 6.5%) ii. CKD stage 3(i.e. eGFR 30-60 mL/min/m2) OR C) Treated (1-2 antihypertensive medications) stage 1 HTN (systolic BP 130-139 and/or diastolic BP 80-89) with or without \>1 additional HF risk factors OR D) Treated stage 1 HTN w/ systolic BP 120-129 with additional HF risk factors: i. Diabetes (HbA1c ≥ 6.5%) ii. CKD stage 3(i.e. eGFR 30-60 mL/min/m2) Exclusion Criteria: An individual who meets any of the following criteria will be excluded from participation in this study: 1. Previous diagnosis of HF 2. Uncontrolled diabetes (HbA1C ≥8.0% from SOC screening labs) 3. Chronic use of insulin or \>1 anti-diabetic medication 4. Self-reported pregnancy (or planning to become pregnant in the next year) 5. Severely uncontrolled BP at screening visits (SBP ≥180 mm Hg and/or diastolic BP ≥110 mmHg) 6. Point of care (POC) BNP measurement ≥400 ng/L. If POC BNP was not obtained, then NTproBNP ≥ 1000 ng/L from screening labs will be excluded. 7. eGFR \<45 ml/min/sq-m on SOC screening labs