Palliative Care for Persons With ADRD and CI in SNF

KEY INCLUSION CRITERIA Patients: * Admitted for SNF post-acute care at a participating NHs following a recent hospitalization * Age ≥ 60 years old * Speaks English (if verbal) * If non-verbal/unable to participate in a conversation and/or unable to make decisions, a legally authorized representative (LAR)/surrogate decision maker who can make decisions for the patient as determined by ACTs staff * Documented ADRD diagnosis in the medical record or history of cognitive impairment (defined as BIMS score ≤ 12) * At least one global indicator for PC at SNF admission (provider would not be surprised if patient died within 1 year, believes the patient would benefit from advance care planning or symptom management; frequent hospital or NH SNF admissions; complex care requirements; decline in function; feeding intolerance; unintended decline in weight; or previous hospice assessment or enrollment and subsequent discharge) Surrogate/LAR: * ≥18 years old * Family member or friend of an eligible patient as determined by ACTs staff * Speaks English KEY EXCLUSION CRITERIA Patients: * Who have previously received or are referred for PC by their primary care team * With a discharge plan within 48 hours of screening * Currently receiving hospice care * Who do not have one global indicator of need * No documented ADRD diagnosis or history of cognitive impairment in the medical record * That are non-English speaking, (if verbal) * If unable to make decisions, do not have an LAR/surrogat…