Provides home healthcare and palliative care for older adults and people living with a serious illness. Services include: - Ensuring care is matched to goals and priorities. - Providing counseling and support. - Facilitating family meetings with healthcare team. - Educating patients and families about what to expect in the future. - Communicating and coordinating with healthcare team. - Recommending management approaches for emotional symptoms and physician coordination. - Assisting with identification of surrogate decision-maker.