Anticipating Decline and Providing Therapy

Eligibility Criteria

• * Age 60 and older at time of discharge from intensive care unit
• * Minimum 72 hour Intensive Care Unit stay in an ICU at Atrium Health Wake Forest Baptist
• * Delirium during ICU stay as determined by positive Confusion Assessment Method (CAM)-ICU score, review of clinical - documentation, or discussion with clinical team
• * Primary care provider in the Atrium Health Wake Forest system or intention to follow with Primary Care Physician in Atrium Health system
• * English speaking
• * Death during initial hospitalization and/or discharge to Hospice
• * Life-expectancy \< 6 months from pre-existing illness (defined as diagnosis of metastatic cancer, cirrhosis, advanced heart failure, prior palliative care referral)
• * Acute Traumatic Brain Injury
• * Continued residence in skilled nursing facility or rehab that prevents ability to complete study telephone call at time of first cognitive screen attempt
• * Prior history of dementia in electronic health record
• * Language or communication barrier that prohibits intervention participation
• * Participant cannot identify family or caregiver contact or family/caregiver unwilling to participate
• * Subject or legally authorized representative (LAR) decline consent
• * Unstable telephone service for contact after hospital discharge
• * Primary residence outside of North Carolina