1. Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
2. VISN 4 Center for the Evaluation of Patient Aligned Care Teams, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
3. Master of Public Health Program, College of Population Health, Jefferson University, Philadelphia, PA, USA
4. Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
5. Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
6. School of Nursing, University of Pennsylvania, Philadelphia, PA, USA