Team-based Versus Primary Care Clinician-led Advance Care Planning in Practice-based Research Networks

Inclusion Criteria: * Can provide verbal consent * Be an adult 18 years of age or older * Has a serious illness(es) or condition(s) that is likely to limit the patient's life expectancy to less than 2 years as defined by using clinical intuition or a patient identification algorithm when possible * Is community-dwelling or is planned to be discharged to a community-based setting * Can speak, read and write in English, French or Spanish * Has had an initial advance care planning (ACP) conversation at a primary care practice participating in this project. Exclusion Criteria: * Patients may not already be enrolled in hospice * Patients may not currently be in an intensive care unit or hospital with no expectation of discharge * Patient may not be in an institution (e.g., nursing home) or awaiting nursing home placement in the near future