ALIGN for Older Adults With Cancer in SNFs

Patients

Inclusion Criteria:

1. Adults between 18-98 years

2. Stage II-IV solid tumors

3. Discharging from an acute care hospital to a SNF in Colorado

4. English speaking

5. Receiving or establishing care at the University of Colorado Cancer Center

6. If a patient lacks capacity, a legal surrogate decision-maker will be approached toprovide proxy consent.

7. Must have access to the technology needed to complete consenting visit andsubsequent intervention visits. This includes internet access through a computer,tablet, or smartphone OR cellular service with adequate allowance of cellularminutes to allow virtual visits (by participant's assessment).

Exclusion Criteria:

1. Discharging with hospice care

2. Age less than 18

3. Lacking capacity without a legal surrogate decision maker or proxy. Patient withlimited English

Caregivers

Inclusion Criteria:

1. Patient-selected

2. Age ≥ 18

3. English speaking

4. Able to complete baseline measures.

Exclusion Criteria:

1. Discharging with hospice care

2. Age < 18

3. Caregivers with limited English proficiency will be excluded as ALIGN interventioncontent and documents have only been validated in an English-speaking population.

SNF Staff

Inclusion Criteria:

1. One of 25 interdisciplinary clinicians from the 5 most common community SNFs

2. Staff must be employed by on of the 5 most common community SNFs named above. (caremanagers, social workers, nurses, physical therapists, occupational therapists,advanced practice providers, and physicians)

Exclusion Criteria:

1. Not employed by one of the top 5 community SNFs patients were discharged to duringthe pilot trial

PCSW

Inclusion Criteria:

1. PCSWs who conducted the ALIGN intervention and consent to an interview