This trial was performed at the two clinics comprising the IHS Gallup Service Unit: Gallup Indian Medical Center (GIMC) Ambulatory Medicine Clinic in Gallup, NM and Tohatchi Health Center (THC) in Tohatchi, NM. GIMC is the largest IHS hospital serving the Navajo Nation, the largest Indigenous tribe in the U.S. GIMC has one of the highest clinical volumes in the IHS and with a catchment area of a 50-mile radius, serves as the major referral hospital for Navajo Nation (see Figure). THC is a small, even more rural IHS site, that provides ambulatory care for approximately 10,000 residents living remotely on the reservation