Advancing Ethical Goals In Society Trial

The goal of this clinical trial is to make sure that the values of older persons aged 65 years or older with Alzheimer's Disease and Related Dementias (ADRD) or increased risk of mortality are known and respected, thereby reducing the burden of intrusive, unwanted medical interventions on their lives. The main aims of the study are: * To assess the impact of our Advance Care Planning (ACP) Counselor Video Program on ACP documentation and receipt of goal-concordant care in a diverse sample of older adults with ADRD or other serious illness * To compare resuscitation preferences, hospice use, healthcare utilization and costs Researchers will randomize participants into two groups. All participants will continue to receive routine care. Participants randomized to the Immediate-Start Intervention group will be offered the ACP Counselor Video Program during both Phase 1 and Phase 2. Participants randomized to the Routine Care/Delayed-Start Intervention group will receive routine care alone during Phase 1 and will be offered the ACP Counselor Video Program beginning in Phase 2. Each phase will last two years. Both groups will have access to the intervention during Phase 2. During the intervention, participants will: * Meet with ACP counselors * Watch ACP videos.

Inclusion Criteria: as ascertained within a month of randomization * Age ≥65 years as of the cohort eligibility/index date * At least one qualifying ambulatory encounter during the 12-month assessment window * One of the following 1. Diagnosed with Alzheimer's Disease or Related Dementias (ADRD) based on a pre-specified ICD-10 code list, or 2. Estimated 1-year mortality risk of at least 20%, based on a prespecified health-system mortality-risk algorithm, or 3. Age 90 and above Exclusion Criteria: * Patients receiving hospice or program of All-Inclusive Care for the Elderly (PACE) * Patients who primarily reside in a skilled nursing facility * Incarcerated patients