The Care for America's Aging Study

Inclusion Criteria for Patients: * Age 60 years and above * Patients in Mass General Brigham healthcare system * Mild cognitive impairment or dementia diagnosis of no greater than mild-moderate severity * Discharge plan includes referral to home care services * As all surveys have been validated in English, we will limit participation to potential participants able to read English. Exclusion Criteria for Patients: * Discharge to Medicare short-term rehab only * Lack of care partner * Enrolled in palliative care (projected survival \< 6 months) * Clinical severity of dementia that is moderate or greater * Any active clinical issues barring safe participation * Montreal Cognitive Assessment (MoCA)-blind score below cutoff * University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) score below cutoff