Older individuals with chronic health challenges face barriers to care including transportation, mobility, health literacy, and unfamiliarity with technology, among others. Our program improves chronic disease management of senior patients through Community Health Workers (CHWs) home visits coupled with Telemedicine/Telehealth. Our organization already has established the healthcare infrastructure for each strategy and is currently implementing each strategy separately in other programs. Thus, this program, will focus on coupling two evidence based approaches with CHWs visiting patients, at home, to assess their needs, health status, as well as helping them learn to engage in Telehealth visits with their provider. Our seniors are an underserved population with many barriers that hinder management of their chronic conditions. This program will identify and address those barriers by connecting seniors with CHWs and UF physicians/providers for at-home and Telehealth visits as well social services through Eldersource.