Inclusion Criteria:  2 encounters in prior 12 months 3 active health problems on active problem list or prescribed 10 medications  Exclusion Criteria:  nursing home resident end stage renal disease on dialysis PCP endorsement of a validated palliative care screening question  the investigators will present a list of eligible patients to PCPs prior to telephone contact to identify patients who the PCP:  a) believes cannot participate independently or provide informed consent due to cognitive impairment b) "would not be surprised if the patient passed away within the next 12 months?"