Clinical Research Directory

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 to provide proxy consent. 7. Must have access to the technology needed to complete consenting visit and subsequent intervention visits. This includes internet access through a computer, tablet, or smartphone OR cellular service with adequate allowance of cellular minutes 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 with limited 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 intervention content 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. (care managers, 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 during the pilot trial PCSW Inclusion Criteria: 1\. PCSWs who conducted the ALIGN intervention and consent to an interview