Palliative Care Population Management Project for Integrated Care Management Program for High-Risk Patients

"1. Clinician training~2. System for patient selection~3. System of triggering and tracking conversations~4. Training on how to use the Serious Illness Care Guide, a guide for patients about initiating conversations with family members about end-of-life goals and values~5. Longitudinal Medical Record (LMR) documentation module to serve as a Single source of truth about advance care preferences in the LMR."