This study focuses on how Community Health Workers (CHWs) can help people with high blood pressure (hypertension) and diabetes by reducing social barriers that affect their health. Social barriers are things in the environment, like where you live or work, that can make it hard to stay healthy. The study is taking place in community health centers (CHCs) where CHWs will screen for social risks and refer patients to services that could help them. The main goals are to see if this helps lower blood sugar and blood pressure and to find the best ways to run these programs.

• The study includes adults 18+ with diabetes or high blood pressure.
• Participants will not be identified in the study, keeping their information private.
• CHWs will gather data to see the intervention's impact on health and if referrals helped improve care.

By participating, you might receive help connecting to services that could improve your health. The study will gather data from your health records, but your identity will remain confidential.