nursing home resident

end stage renal disease on dialysis

active serious mental illness (psychosis, schizophrenia, etc)

active substance use disorder

complete hearing loss

dementia

Non-English speaker (translator required)

4 or more no-show appointments in the last 6 months

the investigators will present a list of eligible patients to PCPs prior to chart review to identify patients who the PCP:

* a) believes cannot participate independently or provide informed consent due to cognitive impairment

* b) "would not be surprised if the patient passed away within the next 12 months?"

Effect of Patient Priorities Care Implementation in Older Veterans With Multiple Chronic Conditions