Inclusion Criteria:

CLINICIANS VA primary care advance practice clinicians (MDs, APRNs) at one of the three study sites able to complete LST notes and orders. Advance practice clinicians will be eligible for randomization if they have at least 15 eligible patients without LST notes at the start of stage 1 (to allow participating clinicians ample opportunities to write notes) and have written fewer than 4 LST notes in the previous year (to select clinicians who need improvement), and can potentially receive the planned implementation strategies, i.e., clinicians who regularly attend the Patient Aligned Care Team (PACT) team meetings. PATIENTS.

• - Veteran enrolled in VHA health care in one of the three study sites who is a current patient of one of the eligible primary care clinicians.

• - Diagnosis of cancer, heart failure, interstitial lung disease, chronic obstructive pulmonary disease, end-stage renal disease, end-stage liver disease, and dementia.

• - Care Assessment Need score of > or equal to 90 using the one-year combined hospitalization/mortality variable.

Exclusion Criteria:

PATIENTS.

• - Prisoner.

• - Pregnant.

• - under 18 years of age.

The aims of this study are as follows: Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness of clinician and patient implementation strategies to improve the occurrence of documented goals of care conversations in Veterans with serious medical illness. Hypothesis 1 (first stage of the SMART): Compared to a low intensity clinician strategy alone, a low intensity clinician and patient strategy will lead to increased documentation of goals of care conversations. Hypothesis 2. Among those who do not respond to low intensity strategies, compared to a high intensity clinician strategy alone, a high intensity clinician and patient strategy will lead to increased documentation of goals of care conversations. Aim 2a. Identify the sequence of implementation strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b (exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation strategies on documentation of goals of care conversations. Aim 3. Understand clinician and patient implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders, patients, and caregivers.

Arms

Active Comparator: No then high patient engagement

First stage: No patient engagement Second stage: High patient engagement

Active Comparator: No then low patient engagement

First stage: No patient engagement Second stage: Low patient engagement

Active Comparator: No then no patient engagement

First stage: No patient engagement Second stage: No patient engagement

Active Comparator: Low then high patient engagement

First stage: Low patient engagement Second stage: High patient engagement

Active Comparator: Low then low patient engagement

First stage: Low patient engagement Second stage: Low patient engagement

Active Comparator: Low then no patient engagement

First stage: Low patient engagement Second stage: No patient engagement

Interventions

Behavioral: - Clinician Implementation Strategy Stage 1

A "booster" of the established LSTDI implementation strategy. Clinicians will be presented with summary written/electronic materials on the LSTDI developed for the study. Online training options and when and how to complete goals of care conversations and documentation will be highlighted.

Behavioral: - Clinician Implementation Strategy Stage 2

This includes two components: Team facilitation to help the primary care team (advance practice provider, nurse, social worker) work together to create roles and responsibilities for accomplishing goals of care conversations with patients A patient list "trigger" of patients potentially eligible for goals of care conversations (the patient study population) will be sent to the primary care clinicians.

Behavioral: - Low patient engagement

Patients will be sent information about goals of care conversations, including the PREPARE website.

Behavioral: - High patient engagement

Patients will be sent information about goals of care conversations, including the PREPARE website. Follow-up phone calls to discuss goals of care conversations and the PREPARE website will be made.