Team-Based Shared Decision-Making Program in Cardiovascular-Kidney-Metabolic Health (Healthy Heart - CKM)

The investigators are proposing a new team-based shared decision-making (SDM) program. The goal of this study is to see whether this program is practical and whether it may help adults with cardiometabolic risk factors and cardiovascular-kidney-metabolic syndrome. The investigators will enroll adults from a primary care clinic in Maryland. People in the intervention group will take part in the 6-month program in addition to usual care. People in the control group will receive usual care only.

Inclusion Criteria: * Are adults aged 18 years or older, * Are in stage 2 CKM: the presence of metabolic risk factors (hypertension \[stages 1 and 2\], hypertriglyceridemia \[≥135 mg/dL\], diabetes, Metabolic Equivalents (MetS)\*) and/or Chronic Kidney Disease (CKD) \[moderate- to high-risk CKD which are stages 1-3 CKD\]), and * Receive primary care at Johns Hopkins Community Physicians (JHCP). * Access to smart phone or tablet to use app. Exclusion Criteria: * Have diagnosis of CVD, * Stage 4-5 CKD, kidney failure, or on dialysis * Have a serious medical condition such as cancer; * Have cognitive impairment; * Are currently involved in other programs on improving LE8; or * Unwillingness to provide informed consent * Unable to speak, read, or communicate in English.