Using Community Health Workers to Support Rural Care Partners of Seriously Ill Older Veterans

The investigators aim to support care partner's well-being and satisfaction with VA care and decrease their work burden by offering extra support from a trained Community Health Worker who will help connect the care partner to helpful resources in their communities and in the VA. The investigators also hope to help Veterans well-being and satisfaction with VA care by supporting their care partner more sufficiently allowing the care partner to focus on caregiving tasks.

Inclusion Criteria: Care Partner Inclusion Criteria * A relative, friend, or partner (18 years of age) with whom Veteran patient has a personal relationship who assists Veteran regularly with care and/or care coordination as defined under "Veterans" below * Residing in a rural area based on RUCC or Rural-Urban Continuum Codes83 * Must be enrolled in CSP Program of General Caregiver Support Services * Can live with or separately from the Veteran; able to communicate in English by phone Veteran Inclusion Criteria * Receiving care at Durham, Asheville, and Richmond VA Health Systems (e.g., at least 2 outpatient visits in past year; has a primary provider) and residing in a rural area. * Diagnosed with congestive heart failure, chronic obstructive pulmonary disease, cancer, dementia, or end-stage renal disease. * Requires assistance with at least one ADL (i.e., walking, feeding, toileting, transferring, bathing, or dressing) or IADL (i.e., transport, medication, financial management, shopping, or meal preparation) * 50 years old or older and able to communicate in English by phone (for assessments) Exclusion Criteria: Veteran Exclusion Criteria * Flag or social work note indicating suspected Caregiver abuse. * Unable to communicate in English by phone for assessments.