ALIGN for Older Adults With Cancer in SNFs

Patients Inclusion Criteria: 1. Adults between 18-98 years 2. Stage I-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. 8. Must have an email address or caregiver with an email address to facilitate communication during the trial Exclusion Criteria: 1. Discharging with hospice care 2. Age less than 18 3. Lacking capacity without a legal surrogate decision maker or proxy. 4. Limited English proficiency 5. Hospitalized for a planned admission or procedure 6. Have any pschological or physical symptom, medication or other relevant finding prior to randomization, based on the clinical judgement of the PI or relevant clinical study staff that would make a participant unsuitable for the study 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. 4. Have any pschological or physical symptom, medication or other relevant finding prior to randomization, based on the clinical judgement of the PI or relevant clinical study staff that would make a participant unsuitable for the study SNF Staff Inclusion Criteria: 1\. Working at a SNF that cared for a patient who received the ALIGN intervention Exclusion Criteria: 1\. Not employed by a community SNF where patients were discharged to during the pilot trial PCSW Inclusion Criteria: 1\. PCSWs who conducted the ALIGN intervention and consent to an interview