Advance Care Planning for People with Dementia

Inclusion Criteria: Primary care team member (PCTM) eligibility: * Must be an MD/APP, employed at a primary care clinic within UNC HEALTH clinics with ≥60 PLwD encounters per year, who sees older adult patients, along with their associated nurses and social workers. * Eligibility for training with AD ACP Toolkit will include the above and the provision of care at an intervention clinic. * For Aim 3, only the trained intervention site primary care team members will be eligible for the implementation surveys or the interviews. PLwD eligibility: * Must be a PLwD age 65 years or older seen by either the intervention or control sites' primary care teams' MD/APP in the 18-month intervention window for Aim 1. * PLwD will be eligible only after we confirm the presence of the AD/ADRD diagnosis. * All PLwD with a ≥50% 5-year all-cause mortality risk seen by the PCTM MD/APP over the 18-month intervention period will be eligible for the healthcare utilization analyses in Aim 2. Exclusion Criteria: Primary care team member exclusion criteria: * We will exclude primary care team members who do not care for older adults (e.g. pediatricians or lactation nurses), are employed at geriatric specialty or dementia specialty clinics, or are without a primary care panel (e.g., only urgent care). PLwD exclusion criteria: * Patients will be excluded if they have not been seen in the past 18 months by their primary care team, or if they do not have a diagnosis of ADRD.