Inclusion Criteria:  Stakeholders:  (1) PC provider (2) Social Work (SW) NH champions (3) post-acute care unit nursing staff and providers (including medical directors) (4) NH leadership, information technology staff (5) PLWD and their care partner(s).  Person Living with Dementia (PLWD)  documented dementia diagnosis admitted for post-acute care age ≥ 60 years if unable to participate in a conversation or lacking capacity to make healthcare decisions as determined by the NH staff/providers, a care partner who can act as a surrogate decision maker in the PCC-PAC.  Exclusion Criteria:  Stakeholders:  -PLWD who receives the intervention  PLWD:  planned discharge within 48 hours of screening currently receiving hospice care