The purpose of the study is to test a new model of care for patients with an ongoing or significant medical condition.

LifeCourse is a late life care approach that promotes whole person care through a structured approach built upon an expanded set of palliative care domains and chronic illness care practices. It includes a trained lay healthcare worker as the primary contact who follows the patient across care settings and over time. The care guide asks patients and caregivers to articulate individualized goals and take part in decision making, and uses a family-oriented approach to understand needs, leverage strengths, and empower families to effectively support the individual living with serious illness.

Inclusion criteria

• Patient has an Allina Health primary or specialty provider
• Patient's medical chart indicates an on-going or significant medical condition
• LifeCourse will invite vulnerable patients to enroll, including:
• Critically ill patients
• Cognitively impaired patients
• Elderly patients, some of whom may have cognitive impairment and/or be institutionalized

Exclusion Criteria

• Patient resides in a zip code which does not lie partially within a 45 mile radius from the Allina Health Commons in Minneapolis, Minnesota.
• Patient has not visited an Allina facility, affiliate, or community partner within the last year.
• Patient is eligible for hospice.
• Patient is actively dying.
• Patient is abusive or is discharged against medical advice (AMA).