Inclusion Criteria:  Age >= 18 years First unplanned admission to the oncology service at Massachusetts General Hospital (MGH) since diagnosis of advanced cancer Known diagnosis of advanced breast, thoracic, genitourinary, or gastrointestinal cancer Receiving ongoing oncology care at MGH Verbal fluency in English Internet/wifi or telephone access Residing in Massachusetts at the time of hospital discharge  Exclusion Criteria:  Admitted electively Discharged to a location other than home or expired during admission Discharged with hospice services