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 * Can live with or separately from the Veteran; able to communicate in English by phone Veteran Inclusion Criteria Receiving VA care at HSA 2.1 (North Carolina and Virginia) (at least 2 encounters in past year, has a PACT/primary care provider) * Residing in a rural area based on RUCA Rural Urban Commuting Codes * Diagnosed with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, cancer, dementia, or End-Stage Renal Disease. * Requires assistance with at least one activities of daily living (ADLs) or instrumental activities of daily living (IADL) * 65 years old or older and able to communicate in English by phone (for assessments) Exclusion Criteria: Care partner Exclusion Criteria -Enrolled in Caregiver Support Program (CSP) Veteran Exclusion Criteria * Flag or social work note indicating suspected Caregiver abuse * Unable to communicate in English by phone for assessments