Inclusion Criteria for Patients  African American (AA) ≥ 65 years has at least two of the following chronic conditions: cancer, heart disease, kidney disease, liver disease English-speaking cognitively able to participate in decision-making discussions reliable internet and telephone access FCG willing to participate in study  Inclusion Criteria for FCG  AA  18 years identified by patient as his/her primary FCG English-speaking; and 5) reliable internet and telephone access.  Exclusion Criteria for Patients and FCG  Axis I psychiatric disorder (schizophrenia, bipolar disorder), dementia active substance use disorder living in a nursing home or assisted living facility residence.