Table 1.

Inclusion and exclusion criteria by type of study participant

Veteran patient
Inclusion criteria	60 years of age or older
	Obtains care in the primary care clinics (General Medicine, Geriatrics, and Women’s Clinic) at the San Francisco VA Medical Center
	Has been seen at least twice in the last year by a primary care provider (a measure of established primary care) and had at least two additional visits to the VA in the past year (a measure of frequent the medical center)
Exclusion criteria	Dementia by ICD-9 codes, clinician assessment, chart review or self-report
	Blindness or poor vision by ICD-9 codes, clinician assessment, chart review, self-report of blindness or the inability to read print on a newspaper, or research staff assessment of less than 20/200 vision on the Snellen eye chart with corrective lenses [42].
	Deafness by ICD-9 codes, clinician assessment, self-report, chart review or research staff assessment
	Cognitive impairment as assessed by research staff of any deficits on the validated cognitive assessments Short Portable Mental Status Questionnaire (SPMSQ) [43] and the mini-Cog [44]
	Delirium or psychosis as assessed by a clinician or research staff
	Does not report fluency in English
	No phone for additional study contacts and follow-up interviews
	Active drug or alcohol abuse within the past 3 months determined by clinician assessment, self-report, chart review or research staff assessment
	Patients who report they will be out of town during their scheduled follow-up interview dates outside of a window of 2 months
	Patients who cannot answer consent teach-back questions after three attempts
Surrogate participant
Inclusion criteria	18 years of age or older
	An enrolled patient must identify the surrogate as someone who could make medical decisions for him or her if needed
	An enrolled patient must give the surrogate’s contact information and give permission to contact their potential surrogate
Exclusion criteria	Self-reported dementia, blindness, or deafness
	Cognitive impairment as assessed by research staff of any deficits on the validated cognitive assessments Short Portable Mental Status Questionnaire (SPMSQ) [43] and the mini-Cog [44]
	Delirium or psychosis as assessed by research staff
	Does not report fluency in English
	No phone for follow-up interviews
	Surrogates who report they will be out of town during their scheduled follow-up interview dates outside of a window of 2 months
	Surrogate for whom we cannot schedule an interview greater than 6 months from the Veteran’s final 6-month follow-up interview date
	Surrogates for whom we have attempted to contact 5 times or more without a response
	Surrogates who cannot answer consent teach-back questions after three attempts