Reducing Disparities in the Quality of Advance Care Planning for Older Adults

Inclusion Criteria for Patients: * African-American or White * age 65 or greater * English-speaking * residing in non-institutional setting * cognitively able to participate in advance care planning * Serious or chronic illness including: metastatic cancer; end stage renal disease; advanced liver disease, heart disease or lung disease; amyotrophic lateral sclerosis, severe Parkinson's disease; 2 or more unplanned hospitalizations in the last year; requiring assistance with any basic activity of daily living * Serious illness based on the following: Clinician answers "no" to the surprise question: "Would you be surprised if this person died in the next 12 months?" Exclusion Criteria for Patients: * residence in nursing home or assisted living facility * diagnosis of dementia or unable to consent * documented advance care plan (living will, health care proxy, MOST form, provider note) * current or prior use of hospice * current or prior use of non-hospice palliative care except inpatient palliative care consultation