Clinical Research Directory

Inclusion Criteria: * have advanced dementia, based on Global Deterioration Score (GDS)\>6 * impairment in at least one activity of daily living (ADL -which is inherent in this level of GDS) * at least one hospitalization or ED visit within the last 12 months * a physician who is primarily responsible for their dementia-related care whose clinical outpatient site is associated with one of the four Mount Sinai sites in Manhattan * a family caregiver willing to enroll * a residence in Manhattan where they are currently living (not in a long-term care facility) * capacity to consent or a legal representative available to provide consent * fluency in English or Spanish, or their legal representative must be fluent in English or Spanish * age \>64. Exclusion Criteria: * Does not have a family caregiver to enroll * Does not reside in Manhattan outside of long-term care facility * Does not have fluency in English or Spanish Doesn't